GW1-2021-05319_Well Construction - GW1_20211001

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for sglo or multiple wells �®
1.Well Contractor Information:
o- `V 14.WATERZONES
�I�i( �. l� \ ` FROM TO D6RCR�170N
weuContmcmrName o1 `�9 R' S R f
o� ZS & Zf,' f;
NC well Cow Certidnation Number � p,+C� 'S. CASIDiG for mdfi-esa�wells OR LQO'R d
�t C e S FROM TO DL4Mrl'F3t TRTCIWPSS MA[OtrAL
t� - IA A- �C Jd!IA ((�S � �� fL fL in.
Cony Nam t 16.]NNER CASING OR TTJBING
S-7
Jftft- 7Z,
O P<04
METER TTDCR►VFSS MA'1'<iBtAL
2.wen Construction Permit M .3 3 3 Z R. '/ m 5� VJ to VC
ListallappltcvbleieOperanuraComuy.S1Dre.Vorlarrce.Inlear-etaJ fL ��
3.Well Use(eheckwen aura): 17.SCREEN
FROM I TO DIAMETER I SLOTSR.E TII[C30q= ' sfATERiAL
Water supply Welk C�/_7 ft 7 tj fL t.�,t m b 3 S
OAgicultural ❑Municipav ublic
❑Geothermal(Hmg Supply) ❑Residential Water Supply(smgte) 1t ft m
OlndustriaVCommerc'ral 06-dential Water Supply(shared) 1L GROVI
FROM To MATERL&L t>asprACEMJWFMVrHOD&AMOtmrr
Mitigation 0 M / GlEt/1
Non-Water Supply Well: g R
OMatitoring ORecovary fL S
Injection Welt
OAquifer Reclunge ❑Groundwater Remediation 19.SANpvGRAVEL PACK d 1e
FROM I TO L M&TEU&L E MPIAC MEff AWMOD
OAquifer Storage and Recovery ❑Salinity Banier Zz g 76, IL
OAgW&r Test OStormwater Drainage S IL
U
OExpaimeDtal Technology ❑Subsidence Control 20.DRILLING LOG atmeb additional sbeelt d
❑Gecahermal(Closed Loop) OTracer FROM 'DO DESCRWnON Cc;der.1 Iswlhaek sin ate
OGeothermal(II Return) ❑Othrx(explain under#21 Remarks) p fL S ( 9-
4.Date Well(s)Compkted: -Ll-21 wen ID# Zv tz Z(o toil SC
Sa.wen Location: Z fL fL
Facay/OwnerName F=ftIDif(ifapphmble) 4 ft. &
1115tiC" ft. tk'
Physical Address.City.and Zip /G 377 2 21.REMARKS
rm6 OR-� aab669y
County Pmcel ldatifirationNo.(PDT
Sk Latitude and Longitude in degrees/minutedseeonds or decimal degrees: 22. motion:
(fwell field,one ki teng is suf6cimu)
366 � t �ti N '7 0 3s( ('7rc 1V _
// Signature ofCatified well Date
6.Is(are)the wen(sx Org< aneat or OTemporary By stgu ft dns form,I hereby curdy An,dw wd/(s)mu(were)aanruaered to aeoorda,ae
with 15ANCAC 02C.0100 or 15A NCAC 02C.0200 We0ComwwftnStmadanir and den/a
7.Is this a repair to an ezistieg welt ❑Yes or QlgW--� copy oftbis rmv,d has bee+pmrided m the wdl owner.
ytbis isa repQtr.jgl ombmwn udl cmnv son t,fomwtbn an d erplatn dw aawr ofd 23.Site diagram or additional well details
relaorwder#21 remarks.nedMnorondwbm*ofddsfotm
i You may use the back of this page to provide additional well site details or well
&Number of wells constructed: / construction details. You may also attach additional pages if necessary.
FarmaldpleirgeulmornwmvwerxWllwddlsONLYwfthdwsmnecaus0adrov,.3ouam SUBNHTTALINSTUCTIONS
submit oneform
9 Total well depth below land Sarfaea f�.,�' M 24a.For Aa Wells: Submit this norm within 30 days of completion of well
Farnuddple weQs1W aff depths#'&ffwvw(eomAp1e-3@200'mrd 2®1M construction to the following:
10.Static water level below top of casing: 3 d (fL) Division of Water Resources;Information Processing Unit.
ynvaterlevel &areQ+ 1617 Matz Service Center,Raleigh,NC 27699-1617
1L Borehole diameter. /t/ (in.) 24b.For Infection Wens ONLY: In addition to sending the form to the address in
t, 24a above,also submit a copy of this form within 30 days of completion of well
12.Well construction method: M0Q - 7/ h'vfs'1 construction to the Mowing:
(Lc au$a,mtmy.cable,aired push ate) Division of Water Resources,Underground Injection Coatinl Program.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center;Raleigh,NC 276994636
24c.For Water Supply&Injection Wens:
13a.Yield(gpm) method of test:
ALso submit one copy of this form within 30 days of completion of
136 Disnfeetion type&Je// We Amount: l well construction to the county health'epartmerd of the county where
constructed.
Form GW-1 North Carohna Depasrment ofEnvaornaunt and Natural Resources-Division of Water Resources! Revised August 2013