GW1-2021-07591_Well Construction - GW1_20210903

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MLL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Iaformation.
14.WATER ZONES
W omrac[or Name FROM TO DESCRDPTION
3� fL so It. t o
NC Well Contractor Certification Number To D
n / / ,/j jj I&OUTER CASING for mu1N-eased vrelts OR LINER: - cable
(.NJnrM�f� 1 t Q , 1 .10 (7, FROM TO DIAMETER THICRNESS MATERIAL
3 fL
096pany Name OF 16.INNER CASING OR TUBING
2.Well Construction Permit M Z21-0 —0060 1250 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well cwutruction peratiu(Le,WC.County.State,Variance,etc) it it. in.
3.Well Use(check well use): % ire
Water Supply Well: sM �O I DIAMETER I SLOTS121 I T C10VES,S MATERIAL
Agricultural OMunicipaMblic f. i. ire
Gcodtermal(Heating/Cooling Supply) Mgt;idential Water Supply(singic) g, R. Da
Industrial/Comme cial Residential Water Supply(shared) 18.GROUT
—1hrilzation FROM 70 MATERIAL EM)"CEMENT METHOD rc AMOUNT
Non-Water Supply Well: 6 R zo R-
Monitoring Recovery R ft.
Injection Well: R. R
Aquifer Recharge QGroundwater Remediation
19.SAND/GRAVEL PACK d 0eable ,
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [)Stormwater Drainage R %
Experimental Technology Elsubsidence Control ft. R.
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG suaeh additional sbeeis if
Geothermal(HeatinglCnolin Return Other( lain tinder#21 Retnadcs FROM TO DESCRIPnON cobr sowroet eta
it. ft.
4.Date Well(s)Completed:g--25-7dZ9 Well W#
50.Well Location:
R R.
Q'I0e1.0.e 1�H�VC�hC'c
Facitity/OwncrName Facility ID#(ifapplicabla) & ft.
ft. ft
Physical Ad*=,City.and zip fL R. V 1
Ran�lalyh 7/ //�132So� 2LREMARKS � t3
county Parcel tderuificationNo.(PIN) ih N
5b.Latitude and longitude In degt eedminutedseoemb or decimal degrees:
(if wc1I ficid,one iattlons is sufficient) 2L Certification:
N w -
6.Is(are)the well(s)EW.—rmanent or OTemporary hoe of Certified well Contractor Date
/ Sy signing this form,I hereby terrify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or 91KO with 15A NCAC 01C.0100 or iSA NCAC 02C.0200 Well Consrnrcrion Standards and that a
/fthis is a repair,fill out blown well construction l4rarmation and explain the nature afthe copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis form
23.site diagram or additional well details:
8.For GeoprobelDPT or Clesed-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.
drilled SS1BlVi�T�AL INSTRUCTIONS
9.Total well depth below land surface: ad 00 24a.For AR Wells: Submit this form within 30 days of completion of well
For multiple writs list all depths if doe—(exanple-3@200'and 2@100') construction W the following
18.Static water level below top of casing: (fL) division of Water Resources,lnformatiou Processing Unit,
Ifwaterlevel is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter- (in.) 24b.For lniedion Wells: In addition to sending the form to the address in 24a
12.Well construction method: _41,j^ F'/t6l e•r� above,also submit one copy of this form within 30 days of completion of well
push,etc.)(Le,auger,rotary,rabic,direr[ construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-M
13a.Yield(gpm) 2-d Method of test:--rr u M g 24e.For @yaterr Suoaly 8c laispn wells: in addition to seeding the from to
t the address(es) above, also submit one jeopy of this form within 30 days of
13b.Disinfection type:t� Qr r-e _ Amount: "' completion of well construction to the county health department of the county
i '