GW1-2021-07416_Well Construction - GW1_20210921

WELL CONSTRIICTION RECORD(GW,-D For Internal Use Qnly
1.Well Contractor Information:
QY 14.WAT'SRZAPiSS -
MOM TO A�IiON t'
WenConundorName sic R 2?-I n- � (M
3 b ItZ R R
NC wen Contractor Certification Number S ` s�kl%g� m,'OUi6R:CASTNG:
U� � y, pI4� FRAM TO DIAMEIFdt : 19I /��'�T� .
iq,cro n ! ` t t1Cl rrlOn— - R 5'
Company Name O T
i6:dNNSIt:CASING!o'R•�2TBING `tI '�-,.
2.Well Construction Permit#: 1 To NAMTlm MATEUAL
Lis!aAopplicable weB construction penults(Le.UIC Canary,State,1447 M Etc) R tL t!L
3.Well Use(check well use): R R ho
Water Supply Well: -17.•SCItEBN_ •: ; _ ::' :.:�� .:
FROM TO i MOVIE= i SLAT SIZE 'THIC>;1tFS5 MA�dt1AL
Agricultural [3MunicipaMbiic U R R in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) R R m
Industrial/Commercial 13Residential Water Supply(shared)
28:'GRtHJr.
Irrigation FROM To MATERIAL VIIIt1=11101)&AMOUNr
Non-Water Supply Well: R R
IM
iYfonitwing Recovery R R
Injection Well:
Aquifer Recharge 13GroundwaterRemedistion R R
Aquifer Storage and Recovery Salinity Barrier FRO A3QiIlt:>ZA�YELI'At It MATEa1ALI Ebtn ACMMMr 1Nk1 =
Aquifer Test (3Stomnwater Drainage R R
Experimental Technology OSubsidence Control R tt
Geothermal(Closed Loop) �yT-c-
�+ 20:23R[Id:LNGLOG:
Geothermal eating/Cooling Return) f3Otber(expim under#21 Remarks)I FROM TO DaSCRUMON eolor h d s j conh.* sire,eeo
© D R Sony cla
4.Date Well(s)Completed:_� 7�zI Well W# _qQR 6 R 5 e
SR Well Location: (�Q IL 30 R
.4 ft. /�✓s 1,(f
Lad Sfac R
Fmilitylowner Name Facility➢#(if applicable) R R
15 C.txJa t.jmd PA. Four Oaks R R
Physical Address,City,and Zip R fL
Id CI 1An CiTC)f 21,3t8titAR[LS
Ca mty Parcel Identification No.(PIN)
5b.Latitude and longitude in degreWminutes/seconds or decimal degrees:
(dwell field,one lat4ong is sanician) 22 Certification: f
N W
ZO?
6.Is(are)the we➢(s)oPermanent or 13Temporary Srgnanne o'1'CemSed wall Contct raor Dafte
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: 13Yes or No with 15A NCAC 02C.0100 or 15A NCAC 02C_0200 Ruch Consmrciian Standards and dual o if ihts is a repair,fill ant known well eawfmctlon it fonnation and erploin the nature of the -Py of this record has been provided to the well owner,
repair under 021 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.For Geopr obeMPT or Closed-Loop Geothermal Wells having the same You may use the bards 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:
3t7- SUBM1Tr� MUCTIONS
F Total well depth below land surface: (it) 24&For Ali Wells: Submit this form within 30 armndulripte wells lhtall depths ifdifferent(example-3@200'and 2@100) days Of completion of well
construction to the following:
10.Static water level below top of casing: 30
(ft) Division of Water Resources.lfwvwr level is above casing use"+� roes,Information Processing unit,
/
21.Borehole diameter. I617 Mali Service Center,Raleigh,NC 276"-1617
t3 ru,)
24b.For Iniection We➢s: In addition to sending the fort to the address in 24a
12.Well construction method: .1�C�1 above,also submit one copy of this form within 30 days of completion of well
(La auger,rotary,cable,direct push,etc construction construction to the following
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Uud�ergroimd Injection Control Program,
106 Mail Service Center,Raleigh,NC 276"4636
139.Yield(gpm) 30 Method of test glow 24c,For Water SanDly&
l7 Injection Wells: In addition to sending the form to
23b Disinfection type: Amount /y the address(es)above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
i
Form Gw-I NoAh Carolina Department OfFaIVironmenral Quality-Division of Water Resources Revised 2-22-20I6
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