GW1-2021-04175_Well Construction - GW1_20210827

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
er FROM TO DESCRIPTION
Well are �1 ti� •�S'' �- o �- �� -- `t mod''►
a�-S1ri�� R tt 1.7r'ct/lt�'e — (� G-�4�►
NC Well Contractor Certification Number tO C r flu M OUTER CASING for malli cased wells OR I.IIVER da
17 `S V� l c�trrl�i �O CSC FROM To D MA
Company Name � onQ v n
t� // I6 INNER CASING OR TUBING thermal dosed
2.Well Construction Permit#: 3�10 ' FROM TO DIADUCE dt TB10»3S 1MATFSiAL
List all applicable weU aons&uctioa permits ft e.WC.Comity,State.Varim+ce,etc.) IL fL m'
3.Well use(check well use): B' & in.
7.
Water Supply Well: IFMMC-- DIAMETER SLOTSIM TRICIQttBS MATERW
3AVicultural DMunicip&Public U n. IL to
Geothermal(H.1t*Cooling Supply) �Resid—tial Water Supply(single) g, tt, in.
Ta QRcsidential Water Supply(shared) 7 18.GROUP
FROM TO MATERIAL namciamw METHOD A AMOu"
Non-Water supply well:
Monitoring Recovery & ?0 n
Injection Wen:
ft. R
gtufer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACH rf a ble
Tdf-Storage and Recovery Salinity Barrier FROM TO 1KATERUL EKPIAC6MENT METHOD
Test [:)Stormwater Drainage R ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRII.LING LOG attach additional sleets if nec ssa
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM To DE4tM MON coin,nard�r,soWrock sere eta
rL cis ts o-
4.Date Well(s)Completed: g a Q I Well ID# 3 l!3 3 R15�0
q R-
Sa.Well Location: ,3 v B' I fL !fir bird- ' p,c(.CtJ`
Facility/Owner are Facility Mff(if applicable) rL fL
" n.
Physical Address.City.and Zip R &
a-)Ace 03os- 'o to t I RE&IARKS
C Ity Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minotes/seconds or decimal degrees:
(if well field,one latilong is sufficient) 27.CerH6eation:
R, a � o ,
D Tem Signature of ed well` atractor Date l
6.Is(are)the wea(s)�Permsnent or porary
By signing this form.I hereby certify that the wells)was(were)constructed In accordance .
7.Is this a repair to an existing well: OYes or QNo with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 WeU Construction Standards and that a
If this is a repair,fill out brown well construction hiOrmation and explairr the nature ofthe copy of this record has been provided to the weU owner.
repair under B21 remarks section or on the back of this foray.
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: I J SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1D (fL) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdiooent(example-3@200�ynd 2®1M construction to the following: � ,
10.Static water level below top of easing: 'a LI) (It.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mnn Service Center,Raleigh,NC 2769SLI617
11.Borehole diameter: (jD.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: above'also submit one copy of this form within 30 days of completion of well
(Le-auW.rotary,cable,direct push,etc-) construction to the following
Division of Water Resources,Underground Injection Control Program;
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: k\,q 24c.For Water Supply&Injection Wells: In addition to sending the form to
address(es)the addts(es) above, also submit]one copy of this form within 30 days of
13b.Disinfection type: o h Amount: 0 completion of well construction to the county health department of the county
where constructed
Form GW-1 North Carolina Department of Fmvitonmcatal Quality-Division of Water Resources Revised 2-22 2016