GW1-2021-04049_Well Construction - GW1_20210823

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WELL CONSTRUCTION RECORD{GW-I1 For luternal Use Only:
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1.Well Contractor information:
�� 14.WATER ZONES i
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FROM TO DFSCRIMaN
Well Contractor
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NC Well Contractor Certification Number 15.OUTER CASING for nTTrliftesed went OR LIN£R It a 'cable
FROM TO DIMf67ER THiC2NFS5 MATERIAL
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onnny Name /x�Jy� 14.INNER CASING OR TrA3ING al d
2.Well Construction Permit#: Z t+ t (q U CL//�V -2-[rf FROM TO DIAMETER THIC"Ess MATERIAL.
List all applicable well construction permits f e.UIC..Counrv.State,Variance.etc.) % M In.
3.Well Use(check well use): fL R ice
Water Supply Weil: 1T.SCREEN
FROM TO 111,41MIErER I SLOT SIZE ITi1CIME55 ]1tATER1AL
Agricultural [)Municipal/Public tL n. In.
t teothermal(Heating/Cooling Supply) Wcsidcntial Water Supply(single) rt, ft, is
Industrial/Commerciai 131tcsidential Water Supply(shared) 1&GROUT
:)Irrigation FROM TO MATERIAL £MPLACEME.NT MEMOD&A410Uh"r
Non-Water Supply Well: A0
ft 2,0 ft' Ke%
Monitoring ORecovery ft. f4
Nection Well:
n ft.
Aquifer Recharge QGroundwater Remediation
19.SAND/GRAVEL PACK lable
Aquifer Storage and Recovery Salinity Harrier FROM To MATERIAL Et1PLACEt1ENT METHOD
Aquifer Test OStormwater Drainage R ft.
Experimental Technology OSubsidence Contra) ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets Uneceeta
Geothermal(Heating/Cooling Return) nOther(explain under 921 Remarks) FROM To DESCREMON come twrdn "Wseek type,OVID sizts etc
& ft.
4.Date Well(s)Completed:S'2�^202� Well ID# n. ft.
Sa.Well Location: ft. q
Facility/OwnerName Facility ID#(ifapplicable) 2 ft. 3 2
c.NdOl Goy geed Rd ft. ft.
Physical Address,City.and zip ft ft Illf0frr3110n 'i
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21.REMARKS
fit�amAhcr, t ' 7n3�r/1
County Parcel Identification No.(PiN) Pry
Sb.Latitude and longitude to degre"Iminutes/seconds or decimal degrees:
(if well field,one b0ong is sufficient) 22.Certification:
N W _a' .202/
6.Is(are)the weil(sl�rmaaent or OTemporary
Sigr of Certified Well Contra r Date
By signing this form,1 hereby certify that the ttiell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or [3No idth 15A NCAC 02C.0100 or 15A NCAC 02C.0200 d ell Construction Standards and that a
!'this is a repair,fill out known sell construction information and explain the nature of the ropy oftlds record has been prodded to the i ell owner.
repair tender 021 remarks secrfoa or on the back of this farm"
23.Site diagram or additional well detailr.
8.For GeoprobelDPT 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: SUSMIT7A[ INSTRUCTIONS
9.Total well depth below land surface: (R•) 243,For Wells: Submit this form within 30 days of completion of well
For mul ple wells lisiall depths ifdi,Qerent(example-3@2m'and�2@11101 construction to the following.
10.Static water level below top of easing: 7 (ft.) Division of Water Resources,information Processing Unit,
lfwater level is above casing,use"+" ` Raleigh,NC 276"-1617
y 1617 Mail Sentee Center,
It.Borehole diameter.��y (in.) 14b,Far Infection Wells In addition to sending the form to the address in 24a
n above,also submit one copy of this form within 30 days of completion of well
IL Well construction metlimb A;r D R t* construction to the following:
(Lc.auger,rotary,cable,d'ncct push,etc.) '
Division of Water Resources,Undergiroued Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Rokigh,NC 276"-1636
139.Yield(gpm) J P Method of test: fl r/i►1 fJ 24c.For Water Suupg(v&Infection Wells: In addition to sending the form to
/ the address(es)above, also submit one copy'of"this form within 30 days of
13b.Disinfection type: S h dGfC Amount: .3.J completion of well construction to the c i unty health department of the county