GW1-2021-02342_Well Construction - GW1_20210527

WELL CONSTRUCTION RECORD (GW-1) _._,_ For Internal Use Only:
I.Well Contractor Information: 3�30�21
14.WATER ZONES
FROM TO DESCRIPTION
Well ContractorNa�yme�✓ /� I
O J ! ! ft. I ft.
0 LI f2 ei C
ft. ft.
NC Well Contractor Certification Number (5.OUTER CASING ford ulti-cased'-'ells OR LINER ifa licabte
rn ( / p FROM TO DIAMETER THICKNESS MATERIAL
✓14 Mil es .1)A-21�t W Q�f /fit /�e�l'ZC �G' © fL / ft. f' in.
Company Name (� 4 e—
p-+ / q r- 16.INNER CASING OR TUBIN eothermal closed too -
2.Well Construction Permit#: hr l• rdr J 5 FROM TO DIAMETER THICKNESS MATERIAL
Lisl all applicable well consb71C110n permits(i.e.lllC,County,State,Variance,etc) ft: ft. in.
3.Well Use(check well use):, ft. ft. in,
17.'SCREEN
Water Supply Well: FROM TO DIAMETER .SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 0 ft. ft. in,
Geothermal(Heating/Cooling Supply) NResidential Water Supply(single) . in:
Industrial/Commercial [311esidential Water Supply(shared) 18,GROUT
_- Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. ,
Monitoring ORecovery
Injection Well:
ft. ft.
Aquiter Recharge 06roundwater Remediation
19.SANDlGRA1 EL PACK if applicable)
Aquifer Storage and Recovery Osalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage
Experimental Technology OSubsidence Control ft• ft•
( p) g ) (explain ) ft. ft. ai'sheets if uecessa
Geothermal Closed Loop) Tracer 20.DRILLING LOG attach addmon
BGeothermal(Heating/Cooling Coolin Return Other ex lam under#21 Remarks b I DESCRIPTION color,hardness,soil/rock e, rain size,etc.
FROM TO
4.Date Well(s)Completed:3� ®.Zl Well ID# I Ll
ft. ft- (
5a./Well /Location: / the, ft. ft. �d��u
/l t+� K u S. f^®Gf/G �i ft. IT .S al s
Facility— / ame Facility 1D#(if applicable) ! ft. ft.
//*( ( � L`itytlz W i KtYI S4r9 lift, Deny" {d/ C ft. ft.
Physical Address,City,&ed Zip
21.REMARKS
Comity Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: :a :? prcc:esSin Unit
(if well field,one lat/long is sufficient) 22.Certif atio M'1u R;td•.Otl
N W
6.Is(are)the well(s) Permanent or OTemporary Signature of Certified W II Contractor kV Date
Hy signing this Jornt 1 hereby certify that the well(s)was(were)consinitled in accordance
7.Is this a repair to an existing well: DYes or UNo with 1 iA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Con.sn•uction Standards and that a
if this is a repair,Lill oil known well construction inlbrmalion and explain the nature of the copy of this record has been provided to the well owner.
repair under !21 remarks section or on the hack a/'this lornt.
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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: s� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �c.dJ� (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
1 itr multiple wells list all depths ifdifferent(example-3 a 200'and 2@/00') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
1f water level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
� fI
11.Borehole diameter: (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
(� 2U above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 0 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
�j k
13a.Yield(gpm) ® Method of test: flaw 24c. For Water Supply& Iniectionl Wells: In addition to sending the form to
r'
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 14T14 Amount: y O^y completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina D2partmenl of Environmental Quality-Division of Water Resources' Revised 2-22-2016