GW1-2021-07775_Well Construction - GW1_20211116

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
L Well Contractor Information:C-
�DCI►V ''Pt/1 .��a -14 WATER ONEs
WeIl Cmftw&r Name FROM TO DESCMMON
tt. n
NC Well Contractor Certification Number 15.OUTERCASING multttased weft)flR LIlNER bh
Nble's &)d (1+//r rnt� FROM TO DIAMETER TffiCBSYFS/S MAM1-R L
Company game O ft. O R' &Y� lo' SPQ-Z/ vovc
16.INNER CASING ORT[7BING` thermalclosedloo
2.Well Construction Permit#: FROM To I DrAMErElt I IMCKN s I MAT1luAL
List all applicable well construction permits(Le.UIC,County,State,Variance,eta) ft• ft. I z in.
3.Well Use(check well use): & R
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSII� THICKNESS MATERIAL
Agricultural EIM aUPublic & K
Geothermal(13eating/Cooling Supply) esidential Water Supply(single) ft IL in,
IndustrialtCommercial 131tesidential Water Supply(shared) 1&GROUT
Irrigation FROM TO MATERIAL EADILACEAIENT b1EMOD d:AMOUNT"
Non-Water Supply well• n22 m
onitoring ORecovery lti M
Injectionwell:
Aquifer Recharge OGroundwater Remediation A9: / "PACK(Ifavolidablel
Storage and Recovery 13SalinityBarrier FROM TO I MATERIAL F.IV>"ACEME"METHOD
rCmeothamal
Test C)Stormwater Drainage ft. IL
ental Technology Subsidence Control K ft.
mtal(Closed Loop) [)Tracer 20.DRUJANG LOG attach additional sheets ff
eatin Coohri Return Other lain under#21 Remarks FROM xo DESCRI •IOx color,hardow.soa/rork bye,wainstm,etc,
4.Date Well(s)Completed: Well ID ft. Pt# (� ft.
?Q ft. L-1- n
Sa.Well Location: n f'C
FK 1(k i urn! Qad t'e r tL R
Facility/Owner Name Facility ID#(if applicable) ft• ft.
45' eefs 0'a fL
Physical Address,City,and Zip n �} ft- ft.
/! e S �dD2�3 b 2LREM4RKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrces/minoWseconds or decimal degrees:
(if'well field,one lat/long is sufficient) 22.Ce cation: ' �PORMATION PR �ESGUNII
N w 51 -a)2
6.Is(are)the well(s) ermanent or Temporary S*aaturC2Sj2&tified Well Contactor bane
By signing this farm,I hereby certify that the well(s)was(were)constructed In accordance
7.Is this,a repair to an existing well: QYes or io with I5ANCAC 02C.0100 or 15A NCAC 02C.0200 Well Constrndion&audards and that a
If this is a repair,fill out gown well construction information and eaplain the nature ofthe copy ofthis record has been provided to the well owner.
repair under 4,21 remarks section or on the back of this form. 23.Site diagram or additional well details:
S.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.
drilled. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 706 Formu ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
ltiple wells list all depths ijdi•jferent(emmple-3Q200'and 2�}a 100� construction to the following.
Ijwarer level is above coring,use
f Static water level below top of casing: 'Soo A) Division of Water Resources,Information Processing Unit,
�/ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. G/y (in.) 24b.For Inlection Wells: In addition to sending the form to the address in 24a
�]
M Well construction method: r'f t( qzo dr above,also submit one copy of this form within 30 days of completion of well
(Le-anger,rotary,cable,direct push,etc.) construction to We following
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636 .
Un.Yield(gpm) Method of test: r 24c.For Water Suooly&Infection 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: t77/7 Amount: (D C7Z completion of well construction to the county health department of the county
where constructed.
Fonn GW-1 North CamlmaDepartment of Environmental Quality-Division of Water Resources
Revised 2-22-2016