GW1-2021-07484_Well Construction - GW1_20211116

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only.
I.Well Contractor Information:
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Well Contractor Name FROM TO DESCRUMON
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NC'GU Contradz Certification
fieatioa Number m a z
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FROM MCXZMS I MATERIAL
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2 Well COnstrnetion Permlt#: �f� FROM TO DIAMETER 'ffiCBTiM MATERIAL
Irst aR applicable weH—u*uction per-u(Le UIC,Cworty,SYae.Variance.etc) IL. IL
In.
3.Well Use(checgwell use): It. tt. in.
17 SCRFFdV .. _:'
Water Supply well: FROM TO DIAMEM SLOT 917E TMCKNM MATERIAL
Agricultural al/Pablic tt. in.
Geothermal(Heating/Cooling Supply) 0oicutiai Water Supply(single) It fr. in.
lndushial/Commercial DResidentiat Water Supply(shared) 18
71-iRation FROM I TO METHOD&AMOUNr
Non-Water Supply Well: d R -2,0 R
Monitoring Recovery M tin.
Injection Well: R it
Aquifer Recharge DGro�dwater Remediation 19 SANDJGR&VEI.
Storage and Recovery DSdmdy Barrier FROM TO MATERIAL EDMACE&FENr METHOD
Aquifer Test DStormw d-Drainage R &
ental Technology Subsidence Control M rt.
Geothermal(Closed Loop) Tracer 2o:-DRUJMG IL Gat addidoi nl If e
Geothanial Coo' Retum Other lain under#21 Remadts FROM To pFacMmaTON color Eardo soH/rork eta
IL n Q�Cr v� YI
4.Date Wells)Completed:L� " / well w# IL -W" It-
Sa.Well Location: IL
Facility/Owner Name J /Facility MR rdamlicabble)le) R It.
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Myysical Address,City,and Tap tt. R
Cormty Parcel t��fi�--�i—oa—No.
5b.Latitude and longitude in degMeM3 9nutes/seconds or decal degrees: L7UdR Se'v I iJ►V
(ifwell field,otre laUlong is sufficiert) 22 t Certification: '
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6.Is(am)the wells) Permanent or Temporary Si f ra Contractor Date
By signing this form.I hereby certify that the wells)was(were)cmiM acted in accordance
7.Is this a repair to an existing well: EjYes or ago with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Cwa&udian Standards and that a
If Ma is a repair•fill out brown well covstruchon information and ag71am the nature of the copy of this record has been provided to the well owner.
repair wtder 421 ramark section or an the back ofrhis form. 23.Site diagram or additional well details:
&For GeoprobelDPT or Closed-Loop Geothermal Wefts having the same You may use the back of this page to provide additional well Site details or well
construction,only 1 GW-1 is needed Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled- SUBM1TIAL INSTRUCTIONS
9.Total well depth below land surface: 3 fo0 t (-) 24a.For All Wefts: Submit this foim within 30 days of completion of well
For mah ie weft list off depths ffdlfferent(emmple-e@200'and 2@100) construction to the following.
10.Static water level below top of casing: e�Y� , UP Division of Water Resources,Information Processing'Unit,
Ifwater level is above casing,use-+•' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. tt « (in.} 24L For Iniection Wells: In addition to sending the fora to the address in 24a
QQ /12 Well construction method: above,also submit one copy of this form within 30 days of completion of well
_ I 1 D .
construction to the following.
(Le.age,rotary,cable.diRct post,
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
1636 Mnl7 Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 67• Lc nr�y 24c.For Waiter Supply&Injection wells: In addition M sentling the form to
1 the addresses} above, also submit one copy of'ft form within 30 days of
13b.Disinfection type: /4 Amount: 010 to- completion of well construction to the county health department of the county
when constructed.
Form GW-1 North C—lina Deportment ofEnviroamental Quality-Division of Water Resources Revised 2 22-2016