GW1-2021-07482_Well Construction - GW1_20211116

I
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
1.Well Contractor Information: J, 6
CS✓ After, S1Q�1 14.WATER ZONES
Well ContrIctorName FROM TO DESCRiPIiON
�3q 5_A
NC well Contractor Certification Number
15 OUTER CASING for mnl6 eased wells OR LINER d a livable
DjlbyiS / `eAl j (At� r_j FROM To DIAMETER THIQ�iES3 MATERIAL
CompanyName W l/ VV , m SDQ 2l I eve
��22 t�7 7 16.INNER CASING OR TUBING eothermal dosed-loo
2.Well Construction Permit#: �7J / 5`' FROM TO DL4NWM THICKNESS MATERIAL
List all applicable well construction permits(ie.UIC,County,Slate Variance,etc) O % 3 6 ft. V in. SW-V0 pre-
3.Well Use(check well use): It. ft. m
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE IMCNIMn MATERIAL
❑Agricultural ❑AlgicipaUPublic M it. in.
❑Geothermal(Heating/Cooling Supply) DICesidential Water Supply(single) n rut
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&GROUT
OirriRation ❑Wells>100,000GPD FROM TO MATERIAL MPLACEMWTAM"MOD&AMOUNT
Non-Water Supply Well: D 3 % geen{ e
❑Monitoring ❑Recovery & tt
Injection Well:
iL ff.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK 017 applicablel
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL I V"LACE hflAT?JETHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control M tt
❑Geothermal(Closed Loop) ❑Tracer 20.DRELLING LOG attach additional sheets if necessary)
❑Geothermal(Heating(Cooling Return) ❑Other(explain under#21 Remarks) I
FROM TO DESCREMON(mlor,baMness,mm7hoek ete)
4.Date Well(s)Completed: 3-1&-Wl Well w# )10 I R �o
Sn.Well Location: ft' U5
1L .�
1�Indv UJ. Mossev 2 rut_ n err'J iC�
F;c ity/ er Name Facility ID#(if applicable) Me
ft 00 fG v'e
- 567 It Kee 01eir 1'4,15; la -)VG 29&Z13 M fL
PhysicalIt. %
Address,City,and Zip �r
Ask O,�Ca2 l5—0 e7 5 21.REMARKS
County Parcel Identification No.91N)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: MRi iJN
(dwell field,one laWang is sufficient) 22.Certification: WFORMATiON.PROCESSIN
N W 2�� a 3-is-,wAt
6.Is(are)the well(s): QPermanent or ❑Temporary Signature ed well Contractor. Date
Bysignung this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 8No 15A NCAC 02C.0100 or 15A NCAC 02C.200 Well Construction Mandardr and that a oopy
Ifthis is a repair,fill out known well construction information and explain the nature ofthe of this record has been provided to the well owner"
repair under 11 remarks section or on the back ofthis form
23.Site diagram or additional well details:
R For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-i is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
dulled' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 006 (D) Submit this GW-1 within 30 days of well completion r the following:
For multiple wells list all depths 1fdiJferent&-inple-30a 200'and 2@100� p per g•
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: rJ ( )
Ifwater level is above casing,use„+^ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: to yy tin.) 24b.For Injection Wells:Copy'to DWR,Underground Injection Control(IUC)
( Program,1636 MSC,Raleigh,NC 27699-1636
A l C 6
12.Well construction method: xy 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc") I comfy environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells prodn' over 100.000 GPD:Cop
y to DWR,CCPCUA
Pemrrt Program,1611 MSC,Haleigh,NC 27699-1611
13a.Yield(gpm) Method of test ►r
i
13b.Disinfection type: HTN Amount:
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 6-6-2018