GW1-2021-06376_Well Construction - GW1_20211123

WELL CONSTRUCTION.RECORD(GW-11 For Intemal Use Only:
1.Well Contractor Information:
RDL Drilling Inc. 14 WA'=ZONES
mom TO Dffi�rION
wen Conbact r Name ft. ft
David Barron fk. ft.
NC Well Certification Number e
2089 FROM 110 numum I MHCH M Ar&MMAL
CompaayNamre -V ft. e8�t ft. in. � %40Jj C,
16.HeaA CASING(ft .jgd
2.Well Construction Permit#• FROM TO D&MWEM I 1HICKNM I MAUMAt.
(r ..
List all applicable well canmuction permits e.(IIC.Comfy, Parlance,ere) ft. ft. in.
3.Well Use(cheek well use): ft ft. is
Water Supply Weil: SCREFAM TO aw+rerttae star see I Ttwctat M I MATE "
1lgriculturai �MtmicipaUPubhc S"'� '�•raft' 1O' C 1��� 5C��� ��•
Geothermal(lieating/Cw1ing Supply) Residerrtial Water Suupply(single) jt, jR in
InduLgtritd/Conu mcid 13Reside-mal Water Supply(shared) i&GROUT
Irri on FMM TO mATER1" EMMI.ACEI UMNEiHOD&AMOltNr
Non-Water Supply Well: ffi j ft. do t
onitoring eoovery tt. ft.
Injection Well: R ft.
Aquifer RedLa ge [ Groundwater Remediation 19.SANDIGRAVEL PACK
Aquifer Storage and Recovery [ Salinity Barrier FROM TO MATMI" F a�►ri NT nmTgOD
fL
Aquifer Test OStormwater Drainage n ft' 1 {' n'\1�.
Experimental Teclmology OSubsidence Comml
Geothemual(Closed Loop) OTracer 20.DMU NG LOG attach addttiosai sbeeS ifseman
Geothemal(H lin Return Other( lain under.#2.1- rks 'FROM tt �i5ft. D ION ttor 5A $i 1,�, �
4.Date Well(s)Completed: �, �` � Well ID#m .S rt. $.5 iL 6 tr`TPtu SaP 21 li
52.Well Location:
$^ kxaye comet-eR.ClA
Faicr"hty/Owwr Niame4� Fac7itq II)#(if applicable) &' ft. t�G Fi�A r
1��� 1_t' �i��1.tE! ! `•�l���t �/��i
Physical Address.CttN and Zip rrs.��� ft.
ft. NOV 2 .12071
21.REMARKS .'
County Parcel Idenh cation No,(PIN) OPT
MR
5b.Latitude and longitude in degreea/minates umads or decimal degrees:
uo R� TiON PROCESSi
(if well field,one WAong is sufficient) 22.Certification:
36l jz53�1 N 30. 6t 16� w gg�� � 10 1
6.Igare)the well(s)C)Permanent or M)Temporary $ignature of Certified welt Conasutor Date
By signing this form,I hereby certify that the weU(s)was(were)constructed w aceordh e
7.Is this a repair to an existing well: QYes or E No with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 WeU Conamcdon Standards and that a
If&&is a repair,fill out known well cwL*%twon ivforinatlwn andegdm the nwwe ofthe ropy ofthis rewrrlhas been providledto the welt owner.
repairwrder#21 remarks section oronOw back ofthishnm. 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 14OW--1 is needed Indicate TOTAL NUMBER of wells constructiondetails. You may also attach additional pages if neoessmy.
drilled: SUBARIT 1.11VS1RUC110NS
9.Total well depth below land surface: • 04 24a. For Ail Wens: Submit this!form within 30 days of completion of well
For multiple wells liar aU depths ifdiferent(eragple-3W00'an12@1M construction to the following:
10.Static water level below top of caxit: (R.) Division of water Resoofti a,Information Processing Unit,
#'water levd is above easing,use"+" i 1617 Mail Service Center,Rateigh,NC 27699-1617
1L Borehole diameter. (hl.) 24b.For Infection Welss: In addition to sending the form to the address in 24a
12.Well construction method: U, � above,also submit m for e copy of this m within 30 days of completion of well
�,.7, constntaion to the following:
(Le.anger.Mary.calkdetect push,de
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service C`cuter,Raleigh,NC 27699-1636 ,
13a.Yield(gpm) Method of test: 246-.ForWSuouW&Iniection Wel In addition tD sending the fom to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health depamuent of the county
where constructed.
Form GW-1 North C:atolma Dqmbneat of Eavimurneatat Quality-Division of Water Resources Revised 2 22-20I6