GW1-2021-04652_Well Construction - GW1_20210514

WELL CONSTRUCTION RECORD F
This form can be used for sinsle or multiple wells
1.Well Contractor Information:
T 14.WAFER ZONES
i
'"'� PROM TO DESCRIPTION �
Weli Contractor Nano 1,fI Q� 1 ?Q2t f t' ft.
i
ft. o
P�rDfn�Slr+t]uf S.OU'CERCASt'.YG formttid-t�sedwe�I ORLIP1ER tfa te1
N('Well Contractor Certification\amber r^ 1��i't��t FROM TO DLIMETER Tti1CK'ESS MATERIAL 1'
q� O a� 1rr i
Well t)rl 111 r)CA DNT-11 ��,. rt. �. � irsr
Company flame 16.ININER CASING OR TiA3itY . 'tlseirmal dosed'!oo
+ SW 0l/ 0 163 EOM ft. � fL D�METER TH[CK%ESS YiATERtAL
2.Well Construction Permit#: tn'
I
lt..t all appkeuble srN owwracliun permils fix.Counn-,Strife.Parlance.etc./ ft. ft. in. I
3.Well lase(check well use): 27.SCREEN
Water Supply Well; FROM TO owl ER SLOTSt2E THICKN MATERIAL
WGROU-C
ft. in.
OAgricultural CMunicipa)JPublic
00cothermal(Heating/Cooling Supply) eesidentfal Water Supply(single)
in.
�tndustrfaliCommercizi aResidential Water Supply(shared) TO CEME�TMETtiOD&A�fOC'\T-irrigation a� 'ft. M'1X i(
I Nou-Water Supply Wall: rr. it.
0M. Onitoring CRecovery
I
Injection Well: ff. fL
CAquifer Recharge Groundwater Rcmediation 19.SAN(D/GRAVEL PACK if tiesblo
FROM TO .MATERAL E?1P1,►C'EME\Tilila'ftOD
--Aquifer storage and Recovery MSalinity Barrier ft. ft.
I
CAquifer Test CStormwater Dramatic ff. £t.
OExperimental Technology OSubsidence Control 20.DRILLING LOG attach additional sheets if necessary
^Geothermai(Closed Loop) OTracer FgDM TO DESCRtP-470\(roiar.hareings soilJroek woe.•rain sit).etc.
CGeothernial(Heating Cooling Return) OUther(explain under d21 Remarks) ft fr.
ft. fr.
4.Date Welt(s)Completed: O ft. fc.
.S.Well Location. - ft. ft. I
r.-C` �
!aulit).O.uie(V me i-*set)ity ID-of applicable)
�r1k k ILL ft. fa
(ot�Pit sical Adddressss.+Rt),and Zip �� ILIrI 21.REMAW
Parcel identifleatiou NO (PIN)
Sb.Latitude and Longitude in degrees/minutesisecouds or decimal degrees: 22.Certification:
(iliac!l field,uric 11001143 suf6etem) I
Signature ofCcrtified Well Contractor Date
6.Is(are)the x'ell(s): 14rmanent or ❑Temporary lfy si!ling!Ms•ffanll./hereby'eerl!fp that the ire/14)gas(it Cr.J Cnaivflet tell!t)atCnrtJall(
u7di lSA N!'a('f7?!'.OlAf/nr lS.A V('A('t72C' 0?tlfl lisil C bt)rtruc•lrtut ltinnlanJ.t unJ Ihul a
7.is this a repair to an existing well: Dyes or 940 trios q/this retard hox beet)provided In the well owner.
if fin..i.s o repair•fill nut kiirnve n•dl truuaucnrm wfnrfnoaan and expl,,m itre ornore of the 23.Site diagram or additional well details:
repair tinter.,2l remarkx.cetvfon or(u)IJIe back ofdrir/null.
You may use the back of this page ro'provide afJdiuonal well site details or tt•elI' '
A.Number of wells constructed: I construction details You may also attach additional pages if necessary _
/•1tr om!lrrie nitetvo:n nr non-t+'Mpr aaplflt•tells O.Y/.F:rlih thr snmr c(r+aslr(uttnu,}•nu cmf
.shalt)one hln,r � 24.5ubmittal Instructions:
9.Total well depth below land surface: {ft.} 24a. For A Wells', Submit this funn within 30 days of camp)etnon Of ttefi
Var uadtiple%,elklaaf all thpili..d differeni fe mark•3ipdw and 2Ca/Ulr) construction to the fallowing
10.Static water level below!op of casing: ��/ (ft.) Division of Water Quality,Information Processing Unit,
10.S:r tic water
level
el.bel o...•" 1617 Mail Service Center,Raleigh,NC 21699.1617
11.Borehole diameter-. 24b. For infection Wells: In addition to sending the 4'orm to the address in 2.a
_ �Y 1� �(in.)
}� above, also submit a copy of this form within 30 days of wmpleuor, of tvetl
12.Well construction method: construction to dtc following.
it c auger.rotary.cable,da,"t push,etc.) Division of Water Quality,Underground Injection Control Program,
1636 Mait Service Center,Raleigh,NC 27699-1636
13.FOR WATER SIfPPI-1'WELLS 0NLt':
�Pm Method of test: 11 t • r 24c.For&"U Drily&Geothermal N'ells: 1n addition to seadtng the form to
13a.yield(gpm) the address(es) above, also submit one copy of this form within 30 days of
CI�11OYiY1P- Amount _ completion of well construction to the county health depanmem of the county
13b.Disinfection type: where constructed.
Rekrsedlan 2013
Form GW-t North Carolina Department of environmem and natural Resotwcs—Division or Water Quality