GW1-2021-07586_Well Construction - GW1_20210903

WELL CONSTRUCTION RECORD_(GW_1 For Internal Use Only: Print Fot Tn
1.Well Contractor information:
14.WATERZONES
We ontractor Name FROItt TO DESCRIPTION
W;06
33w- o �a f
NC Well Contractor Certification Number 15.OUTER CASING for ma1tE eased wefts OR LINER f a cattle
WJ� �v FROM TO DfADIHTER THICt(11fs5 ifATERiAL
QI(� r b It. .�lS ft. ln. G
mpany Name
III INNER CASING OR TiJDiNG thermal et
2.Well Construction Permit#: ;2,%',,� VVk) R FROM TO I OIAMErEit THICKNESS MATEML
List all applleable netl cortaracdou permas r e.UIC..,Counnt State,Variance,etc.) % ft. in
3.Well Use(check well use): R' ft. iD
Water Supply%Veil: 1%SCREEN
FROM TO DL1METER SLOT SIZE TRFCKNESS MATEMAL
Agricultural QMunicipal/Public tt ft. In.
feothermal(Heating/Cooling Supply) �idcntiai Water Supply(single) D. it
Industriat/Commercial DResidential Water Supply(shared) I&GROUT
Ifri ation FROM To MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q fL n e4t + U
Monitoring Recovery ft. ft.
Injection Well: it _
Aquifer Recharge Groundwater Remediation fl
19.SAND/GRAVEL PACK f a ieobte)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACE.MP.NT METHOD
Aquifer Test ❑1Stormwater Drainage R- ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets N necesia )
Geothermal(HeatingbCooling Return) nOthcr(explain under#21 Remarks) FROM TO DEWMPTioN actor,hardne sell4ock Sic.ear
(2 pin
4.hate Well(s)Comptetedy 7 'y�ZOYU well ID# gQ R (GG¢0 n Q l'�
52.Welt Location:
iL iL
Facility/L wnerNarm FacilirylD:(if applicable) R' &
704,.S R 14a;r Qe a-4 C'T'" ft. ft. 3
Physical Address,City,and Zip ft. fL Ice Son Unit
G I Fd r-d 21.REMARKS
County Parcel identification No-(PiN) DW
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laviong is sufficient) 22.Certification:
N W &
6.Is(are)the well(s)�Permanent or [3Temporary Si it of Certified Well Contractor Date
By signing this form.I hereby certify that the wells)was(sere)constructed in accordance
7.Is this a repair loan existing well: [3Yes or [3No Stith 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Tell Construction Standards and that a
if this is a repair•,Tll out Anmtn well construction information and explain the nature of the rapt of this record has been prodded to the well owner.
repair under#21 remarks section or on the back gfthis 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 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.
dnlicd: SIMMUTAL INSTRUCTIONS
9.Total well depth below land surface: two 00 24a. j pr AN Welts Submit this form within 30 days of completion of well
For multiple wells list all depths lfdii ferent(example-3 200*and Zgl flw) construction to the following:
10.Static water level below top of casing: z- 0 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is abate casing,use"+••( 1617 Mail Service Center,Ralelgh,NC 27699-1617
r
11.Borehole diameter. o') 24b.For Inlection Weth: In addition to sending the form to the address in 24a
A n above,also submit one copy of ibis form within 30 days of completion of well
12.Well construction metbod: 1 f Q Gf•�/ construction to the following:
(ic.auger,rotary,cable,direct push.etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Man Service Centel',Raleigh,NC 27699-1636
i
13a.Yield(gpm) Method of test 24c.For Wad Sunk&Iniection Wells: In addition to sending the form to
the address(es)above, also submit one copy of-this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the coitirty health department of the county