GW1-2021-05536_Well Construction - GW1_20211013

WELL CONSTRUCTION RECORD(GW-D) Internal Use Only:
1.Well Contractor Information: a ""
11&44 On
EiWATER'7.oNES , 3 .
FRA TO _DESCRWn0Ni
WellConua ��(OG y CIC
NC Well trectarCertificationNamber 15'OIITER:CA811YG form fiased; s OR'LINER :si Ilcable,r.`:i
FROM I M
MA THICKNESS MA
ft" — 6 it $I c
Company Name
C / / i6:iN11tiiER°CASING ORTONING eothernt21 eliised400 _ . _ ,.
2.Well Construction Permit#: PAIJ-.�n 2 "`tom B tf1 l FROM TO 1 DIAbXM TffiCiavEss MATeRtAL
List all applicable wefl construction permits{are.UIC Counim State,Variance,etc.) ft. ft. in
3.Well Use(check well use): It.
::17:SCREEN •'. .' . ,,; _;:-.
Water Supply Well: FROM TO I DIAMETER sLOTSIze Teictxsss tKn
OAgricultural OMunicipal/Public1. t �• d
OGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) g• fL in.
Olndustrial/Cormnercial residential Water Supply(shared) 18 GROUT
01rrigation ffO Wells?100,000 GPD FRONT TO MATERI" EMPLACENSIffhMMOD&AMOUNT
Non-Water Supply Well: R~ R'
OMonitoring ORecovery ft. fL
Injection Well:
ft. it
OAquifer Recharge OGroundwater Remediation
19.SA.NDIGRAVELT'ACiC(If a eable
OAquifer Storage and Recovery ❑Salinity Barrier FROM To I MATERIAL odCF.MENFNEMOD°
OAquifer Test OStormwater Drainage
OExperimental Technology OSubsidenee Control ft. ft.
OGeothermat(Closed Loop) OTracer 20.DRMLMG LOG attnch additional sheets ld na:ets
OGeothennal(Heating(Cooling Return) OOther(explain tinder#21 Remadcs) FROM ft ft.TO DESCPJMON solo,bardaess,soitiroek eta
4.Date Well(s)Completed:/6 —,24 well ID l # ft ft
5a.Well Location: ti ft
Facility/Owner Name ?Facility ID#(if applicable) R' k'
l��/�""- f" ,ndc- ft. ft.
1 Physical Addrqs Pity,and Zip D
414,REMA RKS,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees(minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification.
q
6.Is(are)the well(s): ermanent or OTemporary Srgnatrss en e rfi eR Contract ; Date
7 Bysigningthisform,I hembyceWfy ihdt the ivell(s)infra(were)constructed in accordance with
7.Is this a repair to an existing well: OYes or ONO 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 WO Construction Standards and that a copy
Ifthis is a repair,fitl our known well construction information and explain the nature of the of this record has been provided to the nneii owner.
repair under#21 remarks section or on the back of thisform.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages ifnecessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: __ 6 00 Submit this GW-1 within 30 daps of well completion per the following:
For multiple wells list all depths if dderenr(example-3@200'and 2 at31001
24a. For All Wells: Original form to Division of Water Resources (DWR),.
10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwarer level is above casing,use
l V 7 24b.For Injection Wells:Copy;to DWR,Underground Injection Control(IUC)
11.Borehole diameter: Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: d1'✓it 24c.For Water Supply and OneIn-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable direct ush,etc.)) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing,over 100.000 GPD:Copy to DWR,CCPCUA
_!s l_�/ Permit Program,1611 MSC,Raleigh,NC 27699-161 l
13a.Yield(gpm) Method of test
7t..Tlif;ln'ecllon tvpe'. .t— _._..._ Amount: .6