GW1-2021-05787_Well Construction - GW1_20211015

WELL CONSTRUCTION RECORD(GW ) . For Internal Use Only:
i Yell Contractor Information:
14.WA- ZONES
Well ConlmAorName FROM TO DESCRiP 7ON
N 11 Connector CeAi6catiea Number 15,Oi3T ER CASING.for molff-eased ttells,OR LIINER a ie
FROM i TO DLL1fEfE TMtIiNESS 3tATER1AL
Cmnpany Name
16'INNER CASING OR TUBING faeotherand ctaked4anal
2.Well Construction Permit a. 7 8.2 al "_'1 FROM 470 lHA ILTM TmCK?MS5 'MATEML
I.Ise all app k%dile etWj cwtsttmtiitat parnti►+(i.e.iti( Cem»(r.:Stare,i'admim.erc.3 '.in. '„�,0 u L
3.Well Ilse(check well use): ft. n.
Water Supply Well- 17.SCREEN
FROM TO DfAMEIER St.OTSiZE THiCKNIM V 11ATFAMIL
Agriculttual nmunicipaupwic �l-��tt ���n. '" Oa.O rr �o dC
Geothermal(HeatingiCooling Supply) [ esidentiat Water Supply(Single) tt.. n. in
PIndustrial-Commencia! [ itcsidem al WaterSuppy,(shared) IL GROUT
lnigation FROSt To -MATERM F-%tM ACUtM'T.SIE7UDD&AblOt,"r
Non-WaterSapph Welle
>w —
Mtxtivaring :itt covvery'; ft. ft.
Injection Weill
ft. 2
.Aquifer Recharge 06roundi+Fater Remediati(if 19.;Sr1ND/GR41'EL-PACtC N icabte)
Aquifer Storage and Recovery OSaiiaity Barrier FROM: TO 3tATER1A7: tatPi<c�ntEtar sfsrHOD
Aquifer TestStormirater,[?rainage �� R." R• S _j DY►
Experimental Technology S»bsidence Ctmtroi tt, 1h
Geothemtal(Closed loop) TracerR 20 DRILtIi1 G WG attadr addltfeirsi sheets tfitisa
Geotbertnai(Heatin oolin Retain Other(er lain under#21 Remaiks) FROM To DESCRiPrfO\ rhardsess.soiUroekamill she.ert
z n.
4.Date 1Vdl(s)Completed: Well PINI - R'
Sit.Weil Location: ft
$k CsCrlir�e►e`�. lu? lrs �:2v n-
FacilitylOwnerNeme Ftiallity`iD}(if
applieable) fl` B' c•,. yy
S-x+ kw •;yea
it ft.
ft, ical Address.Cm,and Zip �
214 REASARJ'S `..
Cotmty Petrel FdenditcaUtm No.(AIN)
e
5b.Latitude and longitude in degreeslatioates/seeoads or aedm 'degrees:
(if rep field,one lat/lo sActe t)
�is 2MCertrcro tion'
7 b,.(or'b 3S"�°[ fJ /© /0 21
6.Is(Are)the tveil(s) ermanent or 0Temporsn 'ipatttre ofCcrtifed 1ve11 Conttacioi Date
Rj stpeirrg lhla fora+,i Ttrieht°Celliuteri 1Ge urlTls),x at/u r»/iruaerrncil in aetixrrilcar�r
7.Is this a repair to an a tsdug tvcll �Yss or �`o trnh ISi!M dC Q2C.1110 ar)JA R'(riC A2C'.AIDD f!Ld/Consimc+laa slondanty sad that a
((this fx a mpafr,fill art k+tmetir Nell cMtclnre7ian h irmalian<atd etplahr the mrtnrr c f the �Pt'afthis;rer u:1 hfcr hmm prrnvded to t lt7 U mercer.
rvpair under=21+vorma*secvinn ar tarYlre hack aff"sjornr. =
23.Site diagram or.additional we11 detaUs:
S.For GeoprobdDPT or Closed=Leap Gi othcrntat Wolin'having the same ' .may use the back of this page to-provide additiot l deli site details or acell
construction.only I GW-1 is needed,Indicate TOTAL NUMBER ttf"itaeiis construction details. You may also attach additional,pttges if necessary.
drilled: SLIBAI_SAL ifNS7'Rtit.rj '6
9.Total%veil depth below land surface Z (R•) 2+ia."For Ail t�tells Submit this foirtl Within 30 dtt}3'of carripla tion of well
Faramh1#e urUx(in all deluhs Ifehffen W,(eava#e-3@20D'.and 2 r@1001 ,
cotutrttcttmt to the:f011owing:
10.Static water level below top of easing: (ft.) Dlv Mau of Water Resources;laforraatian Processing gait. -
ijuvier ieral is above cvshrg•rise-4-" 1617 Beall Serslee Center,"teal igh.NC476994617
11.Borehole diameter: (1a.) 34b:For`laitx : In addition"to Betiding the form o the-address in 24a
Q � � + above also submit mte copy of tltis-faint�%riiiun 3t)clays of completion of well
12.tYei!coastruetioa method: 3ltt constrution to the foilo>nnng
(i.e.neap•,Tatar•,cable.direct pualt,etc.)
Division of Witter Resourm.tlndergrduud.injee"n Control Program.
FOR WATER SUPPLY al'ELLS O;�iL1': 16M Ptlail Service Center,Raletgb.NC 276"4636
13a.Yield(gpm) Method of:test �� 14c.j or♦Pater Sunlit.&Iatectioi-W aV lit it"mon to send'uin the form to
the addresses) above, also-sttbrmt`one copy-of this fiirm within 30[lays of
131r Disinfection 0pe: Am cum completion of well construction to the county health deportment of the eotptty
i►�here constructed.
Forth GW-I Nottb Carolina Dep ronent of Emironmental Quality-Dhision of Water Resources Rertised 2-22-2016