GW1-2021-02414_Well Construction - GW1_20210615

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
1.Well Contractor Inforulation:
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14 WATER ZONES:"
Well Contractor Name FROM TO DFSCREMON
yJCIA �15�\ 6 Q '
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NC Well Contractor Certification Numbs 09
nIOGE�55n� IS..OUTER CASING'for ma " wells.ORLINER ff " bk
Lr FROM TO DUME7Fdt TtIIC101FSS MATF7t1AL
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Co +�y Nano 4- ft- ft - /W 1t t 2 16.1NNER CASING ORTUBIN& thermal clased4opol
2.Well Construction Permit#: 303 9 T(/z FROM TO D1AME1'FZt THICKNESS I MATERL&L
List all applicable well construction permits fi.e.U1C.County,Marc,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft I R. in.
Water Supply Well: 17.SCREEN'.
FROM TO DIA11tETFIt SLOT SIZE i 'TMCi NM AUTERiAL
Agricultural ®Municipal/Public 0 n, ft is �
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft tin.
Industrial/Commercial Residential Water Supply(shared) 18.GRODT_
Irrigation FROM TO MATF7t1AL 109T ACEM EW ME180D&AMOE f
Non-Water Supply Well: G D ft' Nora I
Monitoring Recovery g fL
Injection Well:
:)Aquifer R R
q ergs �GroundwaterRemrediation
Aquifer Storage and Recovery19.SAND/GRAVBL PACK rfa_Geible
[3Salinity Banier FROM 70 1 MATERIAL EfNPWCEIVIffi?l METHOD
Aquifer Test OStormwater Drainage ft. (L
Experimental Technology OSubsidence Control ft. R
Geothermal(Closed Loop) E3TMM 20.DRII LING LDG attach additioml sheets if ne¢ess"
Geothermal Heatin Coolie Return Other(explain under 021 Remarks) I FROM TO DESCRIPnON color,tmdnm,,avrodr dc�
4.Date Well(s)Completed: Well iDt 60 R' Sa & S
5a.Well Location: Q
�� R rt.
Facilit IOwner lame Facility[DO(ifapplicable) ft ft.
Physical Address,City,and Zip fL ft.
aV ,I I A 21.REMARKS. . pp
County Parcel IdendScation No.(PIN) eedJ
5b.Latitude and longitude in degmes/minutes/seconds or decimal degrees:
(ifwcll field,one lat/iong is sufficient) 22.Certification:
N W
6.Is(are)the wells) tdPermauent or 13Temporary Signature ofCcrti6ed ell Contactor Sate
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or EJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Will Constmetton Standards and that a
lfthts is a repair,fill out brown well construction tulformallon and explain the nature of the copy of this record has been provided to the well owner.
repair under 921 remarks section or on the boat of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT 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 if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3�L 00 249. For All Wells: Submit this form within 30 days of completion of well
For muldple wells list all depths 1fd{fferen►(example-3@200 and 2@100� construction to the following:
10.Static water level below top of casing: 20
(R.) Division of Water Resources,iInformation Processing Unit,
lfxarer level is about casing,use/'+^ 1617 Mail Service Center',Raleigh;NC 27699.1617
11.Borehole diameter: 6 (in.) Y
24b.For Infection Wells: In addition to sending the form to the address in 24a
CAA above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: C -" f construction to the following:
(i.e.auger,rotary,cablo,direct push,etc.) g'
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY
/nWELLS ONLY: 16M Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ,l/ Method of test (..) 24c.FOr Water Supply&Infection Wells: In addition to sending the form to
D the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount; �1� completion of well construction to the unty health department of the county
where constructed.
Form GW-i North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2 22-2016