GW1-2021-05444_Well Construction - GW1_20210503

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'��WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information:
Frazier Sentelle Jr 14.WATERZONES
FROM TO DFSCRIMON
\Nell Contractor Nmnc ft. ft
2011 .
ft. rc I
NC Well Contractor Certification Number is.OUTER CASING.for mtrtti<ased'treUs OR LINER'tf liable
Merrill Drilling & Water Systems FROM I TO DIAMETER[ THICF(Nl&SS MATERIAL
rt. & is
Company Name "
(� 16.INNER`CASING OR:TUBING " tbermalelosed-loo
2.Well Construction Permit#:W1-- l db 'c6 l 1xoM TO I DIAMETER THiC NES5 I MATERIAL
List all applicable well construction permirs(i.e.111C.Cotatry,State,r'ariance,etc.) ft. ft. - in. - -
3.Well Use(check well use): R. fL in.
Water Supply Well: ' 17.SIREEN
TO DIAMETER .SLOT SIZE TH.IC[CNFSS DATERIAL
-:Aericultural �MunicipaVPublic 2 ft
eothermal(Heatin Coolih Supply) Residential Water SuPP1Y(single)) n, g,
Industrial/Commercial [311esidential Water Supply(shared) _1&GROUT.. :.
Irrigation FROM TO MATERIAL E T't ACEhMT MLMOD&AMOUNT
Non-Water SoppFAlell: ft. rL _} ;
hjO.Rk�SI1w_Iv�. r:i sv.z��e as.er f.� i I� I-n� '1 t�
R rL
i)q f r.Rt ;har�ee,trGrrlration: nGroundwater'Remediation
19..SANDJGRAVELPACK J.a liable
4` ::<-, - �1�.iic DSalinity k 4t„ AL__ ---____ELiP.LACEMENI METHOD ...
A'urfec Tes� a and Rec e- -_._._ Stormtyai Drain e. FROM.. ro rt�TEla- — `-- --—- -
, f
Fxpenrriental'iechnology Subsidence Control ft it.
eothe'rmal(Clos taeb
CCU ed l oo ) Tracer &DRILLING LOG at additional sheets if necessi
h — — -- —e— -- .
Geothermal iie&ineJCooliri Retu Other(explain under Remarks "0M TO DFSCREFTTON..eok bardnem mile ck. migsim etc)
( _ g' ) ( ) _
I , 1 ){_-if i.;t' t,i.�tS_' et (t��l•al tTt '•R lion_tr_ _ _ -. ...
1
4.Date Well(s}Comp let`ed:J 1-- WeIH:D# - '1 4".0 ft n 1
=,
i .Well Location: -
;..
•"fc R
:
_ ft R
gacilitv'GwrrerN�me ,. .:.. Facility ID#(if livable)
P
,f
PitSsical Address,City.and Zip
- - - - - - - - - -
_ .... . .
:
Parcbl Identification No.(PIN) _ ..-.. .'..----=------------------._...-__
5b..La.titudc-and longitude-in degrees/minutes/seconds or-decimal degrees:.
0fiVell field'one lavlonp ii Sufficient) 22..Certification.,,.-- r,.� �` ` •Sa"I10i1
EE ... .rt_... .. ,.
3= 1=�21
_ " I pEC�Rr(iediV ,Contractor -Date--
.:�.Istare�thcnvell(s) ermAdent or,©ITe'mporary Signa�:,. :'__-;: F.,.,-?�t:r;:r:^;?•c:?;'f,-.. ... ..... .
Hi'$igriin}rhis.fvrm..I herrbt c�irify.il}di ihe,wcll(r)-irds 61")llv)rialrin?icJ in=accordance
7,Isi6i3a'repair.toan-existiogwclLRio.., -. . - ... .+nrirhJ5A1vdC:01C.0100-or-I SANCACO2C-.0200.NelGCdnrttvctianSrandardsandrlmra
If this is a repair,'fip-out known well cotutnrction lnjpnnopon and erplatn the nature ojrhe :copy ojthis record hasbeen pr.m-ldei/-iti'ihe':Nrll-auner,t•- =.= _.. ,_._....
repair tinder 21 refitd.Cv secaan or on the back aftlnsjorm.
33.Site dtagr>im oradtLtipnallvell detatls -
You may use the back.Of;this a e to' lour e
3.For Gcoprobc/DPT or•Closed-Loop Geothermal Wells having the.same P 8, P dr,adc(rtiphaa;well site details or well
construcLon . tatts. You.may also attach additional:pagesjf necessary.'
construction.,only. W-1,is needed Indicate TOTAL iYUMBER of wells +�
drilled:__ _ �001 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface �lli (ft) 24a For'All`1Vells: 'Submit this,' ays,of completion of well
For multiple+rolls list all depths rfdljjerenr(erample-3@200 and 2 rr 100') tonstruction to-the following''i
10.Static water level below top of casing: (ft) Division of Water Resources,information Processing Unit,
Jf water level it share casing,tsc"a i II 1617 Mail-Service Center,Raleigh,NC 27699-1617
.. .. ...
11.Borebole diameter: (in.) 24b.For lniection Wells: in addition to sending:the:fbrm(o'the address in 24a
above,also submit one copy of this,form within 30 days of completion of well
12.Well construction method: ( +� construction to the following: ` I.
i.e.auger,iota,}•,cable,direct path,etc.) -
Division of Watcr Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1.636 Mail Service Center,Raleigh;NC 27699•-1636.
'13a.Yield(,pm) Method of test: 24c.For Water Sunoty& lniection Wells: in addition to sending the form to
the address(es) above;.also submit:one copy of this.form_-wi in-.30 days of
Amount:. completion-of well consiruction,;&jthe county health department-of-the county
%vIf&'constricted: ==` ".
I -
Revised-2-22,2016 Fonn GW=i North Carolina Department of Environmental Quality=Division of Water Resources