GW1-2021-07333_Well Construction - GW1_20211006

1.Well Contractor Information:
'14:'WATER ZONES-.-
Well Contractor Name FROM TO I DESCRIPTION
/ ft. 2 ft. i �l
G/L //! ` �NC Well Contractor Certificationft. ft.ification Number /, (/n z15i OUTER CASING formalti=cased.wens OR•I INER'if a'livable x
�4/� Poo Le, W e J ( � '(/+�I FROM ft TO ft• DIAMETER TRICKINESS MATERIAL
f /
Company Name - x z/� i v ''�`-�
-7 ! :i16 INNER CASING,OR TUBING: eothei maPclosed=loo
2.Well Construction Permit#:_ w D�/G 2-G/ l-Z6 z FROM TO DIAMETER TRICKINESS MATERIAL,
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: '17.SCREEN z:
FROM TO DIAMETER: SLOT SIZE TRICKINESS MATERIAL
❑Agricultural ❑Municipal/Public tt. ft. in.
❑Geothermal(Heating/Cooling Supply) QWe'sidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) '18.'GROUT
❑irrl ation ❑Wells>100,000 GPD FROM TO` MATERIAL EMPLACRIENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
49.`SAND/GRAVELYACK if i''licable::
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer :20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/CoolinQg�Retum FROM TO DESCRIPTION(color,hardness soiVrock e, in size,eta) ❑Other(explain under#21 Remarks) D ft.
4.Date Well(s)Completed:0 2 Z Well ID# ft*
ft• G 4 ((
5a.Well Location: ft. G ft.
(j�inre ham Ve
Facility/Owner N/a�me o j-/ Facility lD#(if applicable) ft. ft.
V �VW e�t.� Gll✓,-G k 2 e ft. ft.
T%vow RAW
Physical Address,City,and Zip 1.(/L f /t/C o2 7512 ft. ft. 0
County Parcel Identification No.(PIN) t non P(O On
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: D
(if well field,one lat/long is sufficient) �n 22.Certification-
2 71.
7
5oin�151(o N - 1.c) 7 W �� 2
-Z.
6.Is(are)the well(s): ermanent or ❑Temporary ie ell Contractor Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or L&<o I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
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 Ito provide additional well construction info
construction,only 1 GjTJ-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: / r� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: wS (ft.)
For multiple wells list all depths ifdii ferent(example--3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing:
Z 24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft.
Ifwarer level is above casing,use"+"r ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells:Copy to6WR, Underground Injection Control (IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: r 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) ! ` Method of test: tV Permit Program,1611 MSC,Raleigh,NC 27699-1611
J C
13b.Disinfection type: Amount: