GW1-2021-04108_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD F,
This form can be used for single or multiple weds
1.Well Contractor Information: 1n
14.WAFER 20NE5
TO DESCRIPTION'
Well Contractor Name ft. fr. '
ft. ft.
NC'Well Contractor Certification Number
15,OUTER CASING for ianiti-ca ed WORS OR LINER if a abk
1 ! q� !f /�� FROM TO DIAMETER TtitCKN99S MATERIAL
a 4, F Vwt i 1 by, (!1 Vnyt ft. fr. 114
in 5 ;91 sf r
Company Name - 16,INNER CASING OR TUBM therrm !oo Y ll dgsed-
�1�-tt �r1� � �QQ FROM --TODIAMETER THtCKNESS. MATERIAL2.Well Construction Permit ft;.. W tY Imo/ ft. ft. I.
i
/tit allapplicohle wall cuuxtructiun permits fix.(ounp',Stare,I uriance.arc./
1t. ft. in.
3.Well lise(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE TnI#.1%NFSS I >tATER1AL
ft. ft.
CAgricultural Olviunicipal/Public
00cothennal(Heating/Cooling Supply) glIkesidenital Water Supply(single)
ft. ft. in. .
73lndustrialiCommercizl CCIResidential WaILT Supply(shared) 19.GROLR
MATERIAL E�IPL�CEME\TMETHOD AMOC\T
FROM TO
Ctrrtaanun ft. G7t� 'ft. {LrlU� Y
Nou-Witter Supply R'cll: tt, tt.
0\4onitoring C Recovery
Injection Well:
CAquifer Recharge --Groundwater Remediation 19.SANDIGRAVEL PACK ifa licable
FROM TO MATERIAL E>SYIAG'EME\TJiEI'ttOD
OAquiter Storage and Recovery OSabnity Barrier
CAquifer Test UStonnw'ater Drainage ft. Ft.
GExperimental Technology OSubsidence Control 20.DRILLING LOG attach additional sheets if rieeessary
.-'. FRM
Geothermal(Closed Loop) Tracer O TO DESCRIP'I'!0\ color,hardness.sa!lroekn•e,•rai++sizaetc.
CGcothcrmal(Hcattng Cooling Return) 00ther(explain under 421 Remarks) ft. ft.
f. ft.
4.Date Well(s)Completed: {1. ft. ,c-•
5.Well Location: fr. ft.
Morin .nrl�jL ft. ft. ti
F4ulnv0wuc:\�Jme J Facility iD-tit'applicable') {t. 1't. (_
md ft. ft.
Pit)Steal Address.Cit).rind Zip ///^����^ 21.REMARKS
PlAfdo I( V a _,� Tr-
Parcel
Identiticatio:,Nn (PIN)
5b.Latitude and Longitude in degrees/minutesisecotids or decimal degrees: 22.Certification:
(if\tc11 field,one lac long is suf ctent) '
Signature ofCcnified Well Contractor Dale
6.is(are)the well(s): ®Permanent or ❑Temporary yy,yti+ufg rhts farm,!herehy cernli'(hill the irel/f)+ta.'61'en7 raii,iratied ill mvirdutici-
ii•rlh 13A NCAC QC.010u no'IS.I V('A('I12(' 0240 if•w/(•uostruc•ntni ltnndurals and Ihri,a
7.Is this a repair to an existing Well: Dyes or V�o cops uJ this rec•nrd has been prrnvideid o,the mall u,t•ner.
11 till..r.,er rept"r.Jill not kurma well crut.,rrucirrn,tn/irvitorma anti erpiwn the ninure of the
repair rneder::2!rotnarkr section or at;the hark a/Ihi.c Jnrrn. 23.Site diagram or RddttlOnR)WCIi details:
You may use the back of this page to provide additional well site detail;or well i V1
8.Number ofwelfs constructed: I construction details You may also attach additional pages if necessary
l•ire uw tu
hrph•inlri ne or ann-uiver.srrpplY v eX 0,V1.1':rilh,dw NOW c narlrucdolt,t'nu can
24.Submittal instructions:
.uhnnlenvInrni
9.Total well depth below land surface: t-005 (ft.) 24a• For All Wells: Submit this form within 3U days of cumplellun of\\ell
l'nr ondnple i,.•l/s lire ell dvpllc,rl drllvren!la.\ruuph•-3fu2(1l1'ring!?!i 1111i'y Construction t0 the f011Ow'ing
10.Static water level below top of casing: 20 (ft.) Division of Water Quaiity,Information Processing Unit,
Il naive let•el r.ohrrrr tnanp.rr..d- 1617 Mail Service Center,Raleigh,NC 27699.1617
/� } 24b. For Injection Wells: in addition.to sending the i'orm to the address in 243
11.Borehole diameter. �tJ .007) 1(in.)
� above, also submit a copy of this form withinwithin3U days of CUS11D1YiWit Of Well
12.NV ell construction method: �a Y construction to the following.
lie auger,rulary,cable.dtre.t push.etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPIN WELLS ONLV: 1636 Mail Service Center,Raleigh,NC 27699-1636
(� _�I Method of test:�,c l 1QNy" 24c,For Water Suonly&Geothermal V1'c�y: In addition to sending theform to
13a.Yield m) ` t r the address(es) above, also submit one co of this form within 30 days of
i3b.Disinfection type: Ch1Or�nP_ Amount: completion of well construction to the county health depannicnt of the county
where constructed.
Form UW-1 Noah Carolina Department of Environment and Natural Resour.es-Division of Water Qualityice\rsed Jan 2013