GW1-2021-04174_Well Construction - GW1_20210827

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WELL CONSTRUCTION RECORD(GW-1) For lntemal Ux Only- F
1.Well Contractor Information: I
14.WATER TONES ,
FROM TO DESCRnrnox
Well Name 35 O ft 3 PD fL 0
367gi & It i pad,
NC Well Contractor CMification NombQ 1 q, I&OUTER CASING for multi eased wdb OR L UR s ble
1A�h cJ I �S � � r% `� �i FROM TO.#qu
y Name
1 INNER dosed
2.Well Construction Permit#: W E FROM To DIAMETER Tffie�Fss MATERW
List all applicable welt cmLWn her permits(ie VIC.Cmmty,�ti Fran-we,etc) It. R in.
3.well Use(check well use): R' ML �
Water Su 17.SCRKEN
Supply well: FROM ITO t I Dh4MEIER SLOT SIZE THICKNE&S I MATERIAL
3Agriculturul DMunicipaliPublic U ft tt m.
Geothermal(Heatmg/Cooliag Supply) CgRestdcatial Water Supply(single) tt ft m,
Industrial/Commencial DResidential Water Supply(.hated) 1L GROUT
FROM TO MAI MMAL EMM MCENOM METHOD&AMODPT
Non-Water Supply Well-. 0' 3 e'
Monitoring QRecovery 3 ft ;o It -
Injection well:
1t R
quifer R-1-V DGm indwatex Remediation
D.SAND/GRAVEL PACK da 'cable
gmf-Storage and Recovery Salinity Barrier FROM TO MATERIAL I I EMPIACEMENT METHOD
Test C)Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 2&DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) - Other(Main under#21 Reniad.) FROM To DFscRiPTtox rotor, a sve,eft-)
4.Date Well(s)Completed:S I UA Java I wen low 3 5 -3 (oO
5a.well Lomdon: 0 fL O R'
�,ovv-k �'X1YiS`IinG �'t°Dtrc,
Facility/OwnerNamer( F- i[tyID9(ifapplicab1c) R' R'
�Zl 0 IRoj,- re e1�i FMl T� sB A lS ft. ft.
Physical,Address,City,and lip C-3 it ft.
zL REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minates/seeonds or decimal degrees.
(if well field,one tat/long is sufficient) 22.Certifleation:
N -;t� ia-i w
6.h(are)the wells)JRPermanent or [)Temporary Signature of tatified Web Can
Date
By signing this form.I hereby ' that the well(s)was(were)constructed in accordmree
7.Is this a repair to an eAsting well: E]Yes or RNo with ISANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fell out brown well construction mformation and explain the nature offhe copy of this 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 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: Q SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ' U S (II-) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i#�went(example-3@200'mull@100) construction to the following:
10.Static water level below top of casing: Division of Water Resources,Ltformation Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Ceuter,Raleigh,NC 276994617
11.Borehole diameter. (in-) 24b.For Iniection Wells: In addition to sending the form to the address in 24.
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 141 Lau construction to the following. pp
(ie-auger,rotazY.cable,direct push,etc.) I
Division of Water Resources,1 Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: l q 24c.For Water Suvpb&Injection Wells: In addition to sending the form to
i !� the address(es) above, also submit one copy of this fog within 30 days of
13h.Disinfection type: -tv Amount: 1� ©Z- completion of well construction `to`the county health department of the county
where constructed. 4
4
Form GW-1 North Carolina Department of Favisonmental Quality-Division of Water Resources Revised 2-22-2016