GW1-2021-07397_Well Construction - GW1_20210921

WELL CONSTRUCTION RECORD (GNN-I
1.Well Contractor Information:
14.N4'Al I-P.IONES
tRO%t lu DESLRIF
\k elt Conlractor Name '0 ft.
10
NC A*cii Contractor Certification Number 0A
15.OLTER CAS NG(formulti-cased*elb)OR 1­11�19
FROM 1 10 DIANIETIER
in.
Company Name CA ING t3R TtBiNG(geoflaefaaal c*�-� ------------------------
FROM T( DIANICTER T 14 E 7--
2.Well Construction Permit
List ell/oplAcable 1i ell t onso-ti4 lion permits(i.v. 13C Onin I)%Stole -i nl ite. ft. it. io.
3.Well Use(check well use): ft, ft. in.
17.
Water Supply Well. FROM SCREEN
- . - -' TO PlikVIETER_ _SLOT SLU -S :.�I %TERIAL
:]Agricultural Dxfunicipal Puhlic in
'20 < 'I
ni c
:)Gcotlicial(Heating Cooling Supply) [Residential atcr Supply(singic) ft, in. 7
:)Wustrial,cominercial [Residential N\atcr Supply(shared) 18.G-ROL T
;?flrrigation FROM ft) 'rT
k%I0UNT
Non-Water Supply WeIT- ft. 'V'5'f1
:)Monitoring ft.
Injection Well:
3Aquifer Recharge []Groundwater 11cinediation
19.SAND GR.-%%.LL P kCK(if applicable)
:JAquifer Storage and Recovery [Salinity Barricr FROM T�) NIATURI At.
Aquifer Test [Stonnwater Drainage 4<ft. �/
:)Experimental Technology' [Subsidence Control j ft. ft,
Geotliemial(Closed Loop) [Tracer 20,DRILLING LOG(attach additional sheets lfwcemm-
Geothermal(HeatinWCooling Return) nOther(ex lain under#21 Remarks) I-R(J\1 TO — OFSCRIPTION(coiw, 'trj
ft. f'. Cr
4.Date Well(s)Completed: el Off Well I D ft. •
* .7
5a.Well Location:
Facility Owner Name Facjiir%TD--,(it'applicable) ft- 1;-1
ft. ft.
Physical Address,City,and Zir ft.
f
21.REMARK-%
County Parcel Iderilificatiou js'o.(PIN)
5b.Latitude and longitude in degreesinflnutest'seconds or decimal degrees:
(ifwcll field,tine laulong is sufficient) 22.Certificati9a)
qq 6VQ ­N
7 r
6.Is(are)the well(s) Permanent orDTemporarN \k Contractor
3. ,rrpr,I iligehl-rerfijt that the
7.Is this a repair to an existing well: [Yes or [ONo .1 J,ana
It this is reludr.fill oat known welt conxinn-lion inforsnamm ana,kplain the '0n! 61W re,tact his been provided to the,well or-,.:_
repair under#11 remarks see ttoiz or an the letick of this firm 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 I page to provide -c-t. _'~tails
construction,only I CsW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ft-) 24a. For All Wells: Submit this form —letion c•:
1--or nuittiple t,'etht list all depths tldiftreltr(example.-3((�,200'and construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Informadoe Unit.
It ivater level is ahtwe easing,we 1617 Mad Service Center.RAk-itz L N C -V*t-I t I
11.Borehole diameter: (in.) 24b, For Injection Wells: In addition to --:-t addre-­,
Aj above,also submit one copy of this form -­mpletior,
12.Well construction method: construction to the following:
(i,c.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Infectiroc Control Prog"r>_
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh.NC 2 76"-1636
13a.Yield 4gptn) 20 Method of test: 24c.For ater Supply&Injection%Neils: In kz: n, -.Q sending the
the address(es) above. also submit on: copy of armor. within �O :a
Amount: completion of well construction to t'ne cownt\ neah,-. - partrncnt of dw- :,­i:
13b.Disinfection type: z -,re constructed.
Form GW-I North Carolina Department ofFmironntental duality-Mision of Water Resources Retire, 2-22--'