GW1-2021-03615_Well Construction - GW1_20210823

PY EWUA� for internal Use VNLY:
This form can be used for single or multiple wells L
1.Well-Contractor Information:
14.� 1,1 n VeeVf ��F/�r� l4- �rrl RO.NATER TO
DESCRIPTION
Well Contractor Name ft. ft. 1010
a0 3& ft. ft i
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER da livable
/ ,/ FROM TO DIAMETER THICKNESS MATERIAL
fL
U49
Company Name 16.INNER CASING OR TUBING 1peothermal closed400
^ D FROM TO DIAMETER THICKNESS 1ATERIAL
2.Well Construction Permit#: • (_71� fL ft. in.
List all applicable well construction permits(i.e.Countjt State.Fro iance,etc.) fL ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well• FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft.
❑Agricultural ❑Municipal/Public ft. in.
in.
❑Geothermal(Heating/Cooling Supply) �idential Water Supply(single) ft. ft.
18.
❑Industrial/Commercial ❑Residential Water Supply(shared) F GROUT
ROM TO MATERIAL EMPLACEMENT METHOD&r4M0[NT
❑irri ation O ft O fa °Ven r n r�te K re
Non-Water Supply Well:
it. ft.
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK rf a livable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage IL ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LQG attach additional sheep if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROMTO DESCRIPTION color,hardness,suft1mck e, n six em)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) t1O ft•4.Date Wells Coro feted: V " 5 — 0ft .5c) p y5 ft-S.Well l ocation: aOO1La Mr� AL' e- ..-t77 J ft. I ft.
Fa ity/Owner Name Facility ID#(if applicable)
IL ft.
86 l 41 Mao res 4/"1/10 IL M ��
Physical Address,City,and Zip 21.REMARKS
County Parcel Identification No.(PIN) �o fc
5b.Latitude and Longitude in de�ees/minutes/seconds or decimal degrees:
22.Certification:
(ifwell field,one latlong is sufficient)
3S, �+8103 N 8o t 7ayof� W
Signature ofC&tif ed Well Contractor Date
6.Is(are)the well(s): fdl'ermanent or ❑Temporary By signing this form,i hereby certify that the nvell(s)was(were)constructed in accordance
with I SA NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or 0i0 copy of this record has been provided to the well owner.
If this is a repair,fill out Arno wl well construction information and ecp/ain the nature of the
o
repair under#21 remarks section or on the back of this form. Y Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,your car
24.Submittal Instructions:
submit ore form.
9.Total well depth below land surface: D'o O (ft.) 24n. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2©100') construction to the following:
10.Static water level below top of casing: 35 (ft-) Division of Water Quality,Information Processing Unit,
If hater level is above casing.use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter! ! (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: /?,0]'La✓y construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY
CWELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
23a.Yield(gpm) J Method of test: I/' 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
the address(es) above, alsoisubmit one copy of this form within 30 days of
3 nr'n fS completion of well construction to the county health department of the county
13b.Disinfection type: / /y Amount: where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.201: