GW1-2021-03151_Well Construction - GW1_20210625

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
'
l4,WATER ZONES
G. !
OM TO I D
Well Co�actorName DESCRIPTION
ft. Ce0 ft 1 i KkA ivWCt✓A'+C-
N 0- W e �s s�-l� 1v� �, r� 2021 &C, & % & 0,.M.P-( TAV, ecru
NC We((CbnM*or Cmtkation Number Urllt 15.OUTER CASING for meld-eased wens OR LINER if tieable
J ���1 � FROM To DrAMa TerctaaF�s teaTFu
L4ME-1 C.A-4 vA1L- t_ Tres,,, ,�o_t, © ft, �a �/ �.t-ts 'U�
Company Name ` 16.INNER CASING OR TIIBiNG of atosed400
2.Well Construction Permit#' FROM TO DIAMETER Ttmckr4m MATERIAL
List all applicable well COnStrUCtian permits(r_e.UIC County,State,Yariance,etc.) ft fL
3.Well Use(cbeckwen use): &
iIkrigation
ter Su 17.SCREEN
PPIY Well: FROM TO DIAMETER SLOT SUE 7HICKNESS MATERIAL
gricultural OMunicipal/Public 60 IL 4010 ft j + to .C,(G. ��40 Pv.
eothermal(Heating/Cooling supply) OResidential Water Supply(single) ft. in.
dustriallCommmial OResidential lWater Supply(shared) is.GROUT
FROM TO I MATENIAL EMPLACI MFNTML?HODAAMOUNT
Non-Water supply wen: a & zs 1t
Monitoring Recovery % &
LMectlon Well: n tt.
Aquifer Recharge OG oundwater Remediation
19.5AND/GRAVEL PACK a cable
Aquifer Storage and Recovery OSalinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. &
Experimental Technology ❑subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if
Geothermal(Heatingipooling Return Other(explain under#21 Remarks FROM TO DESCItTMON corer,hardnemsofilreck typa,vain etc
d- ". /p CtA-(�51Wb
4.Date Wells)Completed: /S Well PD# (O it- /5 fL CI-A-( I 5'Me= t igA-M
59.Well Location: /S I, Ss ft. S4ai1�/spek-a 5 'w- ci+ 'l
:?4-vL W I U-r4A S .3S ' Coo & ' '
Facility/Owner Name Facility iD#(ifspplitable) a it. q0 IL S44S C--kA#J F 4'r.Kt-
IR.I_SuhmuFQ tslP�_.A.P=Fc1�E�.tTo�1 Nc•_ �7932 0 % ioo ft ' . L, wt•7
PiWaicel Address,City,and Zip
tr. ft.
1 Q6t.J ►.l 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 21 Certification:
3 4? . o.s l a '1 N ' 7Co. Cn.S`71 S W -Y�& 4L.�Zr—
6.Is(are)the well(s)5Permanent or IDTemporary Signature of Certified Well Contractor Date
�— By signing this form,I hereby certify that the WII(s)was(were)constructed in accordmtce
7.Is this a repair to an eAsting wen: OYes or WNo with ISA NCAC 01C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
If this is a repair;fill out browm well construction information and explain the nature of the caM of this record has been provided to the welt owner.
repair ureter#21 remarks section or on the back of this form
23.Site diagram or additional well details:
9.For GeoprabelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled SIISMiTTAi.INSTitIICT[tJ1�tS
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9.Total well depth below land surface: ( ) 24- For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiff t(example-30200'and 2Q)001 construction to the fonowing:
10.Static water level below top of casing: / (M) Division of Water Resources,Information ProeeWng Unit;
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276W1617
11.Borehole diameter: 7 7& (im.) 248.For Infection wells: In`addition to sending die form to the address in 24a
above,also submit one c*of this form within 30 trays of completion of well
I2.Well ewnatruction method: te1�t!i> TA 2Y construction to the following":
(i.e.auger,rotary•cable,direct push,etc.)
Wdstoa of WateriResooie+eets,Uadergroaad Injeetloa Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Man Service Center,Raleigh,NC 276WI636
t k:. t• E 1
13a.Yield(gpm) S G,POIl Method of test: 1��J wisp 24c•For Water Simply&Injection Wells: In addition to sending the form to
Leivw\ i{YP#C,tjtkC-rJL a the addmss(es) above, also'submit one copy of this form within 30 days of
13b.Disinfection type: Amount. / oZ- completion of well construca n-to the county health department of the county
where constructed
Form GW-1 North Carolina Department of Environmental Quality-Division of Water It lesodirces Revised 2-22-2016
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