GW1-2021-05461_Well Construction - GW1_20210615

WELL CONSTRU TLO-N RECORD(GH-11- For Internal Use Only:
i.well contractor Information:
-.14I.WATER ZON.ES
--m I - FROM TO DFSC UMON?
Well Contractor Name
ft Lf_e-,?ft Ll
NC Wall contractor Cortification Number WOUTER Trals)O&LIlaw(Ifalipli
CASING, kable
ft-T TiRCKNESS A
V% FROM TO _ -MATERIAL
4 ft, I & I U in.
Company ame liNG
3%L 1,1-1,CAIGOR I MAT.12:UAL
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2.Well Construction Permit#: '�e FROM TO & DIAWLM
List all applicable well construction permits e.UIC,County,State,Parlance,etc.) ft.
3.Well Use(cbeckwell use): & ft in.
M'SCREEM.
It"Water Supply Well: FROM TO DIAMiTER I SLOT SUM I TlHCJQMS MATERIAL
flAgricultural 13Municipaliftblic 0 & ft in.
RGeothermal(Heating/Cooling Supply) residential Water Supply(single) & ft in
Industrial/Commercial DResidearbal Water Supply(shared) 1g.GROUT
Ittrigation FROM TO MATERIAL. I EMACMW I 90D&AMOUNT
Non-Water Supply Well: ft. & e- A9,01.1-d
jMonitoring E)Recovery ft ft. v
Injection Well:
ft &
Aquifer Recharge [}Groundwater Remediation
�19.SANDIG]WAVEL*PACK(ifiOpUcAblii)
Aquifer quifer Storage and Recovery C)Salinity Barrier FROM TO MATERIAL W EMPLACEMEMEMOD
Aquifer Test OStormwater Drainage ft &
Experimental Technology 13 Subsidence Control & fL
Geothermal(Closed Loop) Tracer 20.--D .- G-LOG`(atthib&4diSoid M
ibetfoifnetiiy)',"L-
( .hardness,
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) 1 FROM TO DESCRVTION color sollfrock zz)
ft
4.Date Well(s)Completed: well ED# ft gwe
59.Well Location: &
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Facility/OwnerName Facility M#(ifopplicable) ft ft.
2yo,? Tr4 16fG2er & ft
physical Address,City,and Zip & &
LOq k,4, 21L REMARKS
47
County parcel Identification No.(PIN) — ee
W Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if-11 flold,one Istilong is sufficient) 22.Certification:
N W ��P'4e
6.Is(sre)the well(s),515-r-flnent or Temporary Signature--oCertified Well Con cunt Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or UN'o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
ff1h1s Is a- e,Pairfill Out known well construction information and plain the nature of the copy of this record has been provided to thew OW I well ner
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I Gw-i is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9-Total well depth below land surface: -S-6 L/ —Vt
en example.3@200'and.2@100�
For multiple wells list all depths Udfflir t 24a. For All Wells Submit this for ml within 30 days of completion of well
construction to the following:
10.Static water level below top of casing:
If level is above casing,use (ft) Division of Water Resources;Information Processing Unit,
1617 Nbil Service Center,Raleigh,NC 27699.1617
11.Borehole diameter: 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: PQ fdP I/ above, so submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct pusb,cu.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
139.Yield(gpm) 19, Method of test-, 24c.For Water Supply A Iniection Wells; In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type- Amount: completion of well construction to the'county health department of the county
where constructed.
Form ow-I North Carolina DOParnment of Environmental Quality-Division of Water Resources Revised 2-22-2016