GW1-2021-00961_Well Construction - GW1_20210404

RECEIVED
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: !� / q
1.Well Contractor Information: A P R :q 4 2021
c a l s 14..RATER ZONES,. . .. {, .;.
Well ContractorNamc FROM To DESCWPR i
ft. a d
ft 1L
NC Well Contractor Certification Number 15 OOTER CASDVG'for miittletsed teRe'.UR3ATiP3t' 1Ae a . f` <': ,
FROM TO D TtDCRN�F/S.S MATERUL
company/1eme tN G` iG q
�� M INNER'CASING .OR TUBING claeedd - -
2.Well Construction Permit#: (,U FROM TO DIAMETER i MUCHTMS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) fL EL in.
3.Well Use(check well use): M fL in.
Water Supply Well: 17.SCREEN .7.7.
FROM TO 7in.
SLOT SITE imicK IEss MATERIAL
OAgjcuihual OMunicipal/Public tl, it,
i
❑Geothermal(Heating/Cooling Supply) ❑Atsidential Water Supply(single) fL fL
01ndustrial/Commercial OResidential Water Supply(shared) 18 GROUT-
v
Olnigation O Wells>100,000 GPD FROM TO MATERIAL EMMACEMENTMEINOD to AMOUNT
Non-Water Supply Well: G ra ft D'e-
❑Monitoring ORecovery fL ft.
Injection Well:
ft. ft.
OAquifer Recharge ❑GroundwaterRemediation 19:SAND/GRAVEILi�ATK"
OAquifer Storage and Recovery ❑Salinity Barrier FROM To MATEPJAL EMPIACEMEnTMETHOD
OAquifer Test OStomlwater Drainage M ft-
OExperimental Technology OSubsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20:DRIILLING LOG'attach add idood sheefs Hneeessi
OGeothermal eating/Cooling Return ❑Other(explain under#21 Remarks FROM TO DFSCRIMON color budam eo➢/rocir tm grgo dai etc.
ft. ft
G ! ISO,,
4.Date Well(s)Completed: Well 1D# fir. �' fL C,/6
So.Well Location: fL . (L J 44;
9041/ Kuf-5er .S"'d It. m lj�rnj'y�
Facility/Own6rNam Facility ID#(ifapplicable) ft. ft
00 Adnit Pearce_
Physical Address,City,and Zip ft fL
rinkl;� 3LREMARKS ;
Cowry Parcel Identification No.(PIN) e$ &V,& AVe- S,.
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(ifwcll field,one IMong is sufficient) 22.Certification:
N W
6.Is(are)the well(s): 2115'ermanent or ❑Temporary• Signature o£Cerfified well Contractor Date
By signing thisform,I hereby cer*that the iveU(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 6N-o 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out Anawn well construction information and explain the native ofthe ofthis record has been provided to the well owner,
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I GW I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
filled' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (fL) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 2@1001
Ststic water level below top of casing: a.0 (�)
24a• For All Wells: Original form to Division of Water Resources (DWR),
10.
St a if live!is above casing,use'+^ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (m,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Q Program,1636 MSC,Raleigh,NC 27699-1636
IL Well construction method: ,`G4w-X 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,able,direct push,etc.) county environmental health department of the county where`tns�ed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) ,#J/Vi/ Permit Program,1611 MSC,Raleigh,NC 27699-1611
Method of test:
13b.Disinfection type: Amount: Im
Form GW-1 North Carolina Department of Environmantal Quality-Division of Water Resources Revised fr6-2018