GW1-2021-00059_Well Construction - GW1_20211109

WELL ®Fal;9`�� �'�g®��t(��� For internal Use ONLY:
Tlits form rnn be used for single or multiple wells
1.Well Contractor Information: 14.WATER ZO VES
,,Yet. -v n `�p!/S /a-e FFreu Tced7 Pr FROM fc To RlPrtov
S- 3
Well Contractor Name
rs( � is.OUTER CASING for malt'ca§ed welts OR LINER if a licnbte
NC Well ConnactorCeniftcofsonNumber FROM To DIAMETER TstCKNESS vtArERIAr
ft. $ ft. & n•
16.INNER CASING OR-'TUBING eothcctnalclosed-hio
Company Name FROMTO DIAMETER 'r]DCKNESS MATERIAL
ft. in.
2.Well Construction Permit#: 00 7 3 3"-3-
List all applicable+veil construction permits(i.e.C0110'State,Variance,etc.) ft ft. in.
3.Well Use(checkwell use): 17.SCREEN
FROM TO D]A.NIETER SLOT SIZE THICIfNESS MATERIAL
Water Supply Well: ft. ft. in.
OAgticultural OMunicipal/Public ft ft in.
OGeothetmal(Heating/Cooling Supply) pfesidential Water Supply(single) 18.GROUT
❑Industrial/Commercial ❑Residential Water Supply(shared) FROM TO MATERIAL &\1PLACE�9Fa\T METHOD&AMOUNT
Olrri ation 0 ft• fL ��' '�
Non-Water Supply Wei I: it, it
OMonitoring ❑Recovery ft. R.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation FROM TO
EL PACK Cf a licabtel EMPLACEMENT METHOD
<IATERIAL
OAquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft. ft.
oExperimental Technology ❑Subsidence Control 20.DRILLING LOG(nttaeb additional sheets if necess
C7Geothermal(Closed Loop)
OTmcer FROM TO DESCRIPTION(color,hardness,solllrock e, nin she,Cie.)
(Heatinil./Cooling Return) ❑Other(explain under#21 Rematits) Z O ft. 2� ft.
4.Date Well(s)Completed: :8 + ,2 '
d
5.Well vocation: g7 rL QJ ft ft�
�PilkyDID#(if applicable) fL ft.
Facilietyt/Owner Nam�e
_8v/O f'iRpD pI �l� C�h�N U.*-- ft. ft.
Physical Address,City,and Zip 21.ROMARKS _
County Parcel Identification No.(PIN) 0
5b.Latitude and Longitude in degreesiminutes/seconds or decimal degrees: 22.Certification: DWR SECTION
(if well field,one/ladlong is sufficient) � / O 4� � � , `'- MATION PROCESS�PUi �- Z/
35• �(fJ A5 • N g�. W Date
Signature ofCettified Well Contractor
6.Is(are)the vveil(s): lirmanent or ❑Tempora ry By signing this form.1 hereby certify that the ivell(s)ivas(were)corrstructed in accordance
wid+ li.t NCAC 03C.0/00 a•15d NC:iC 02C.0300 1]'el/Constructimr Stm+dards and that a
�� copy of this record has been provided to the ivell owner.
7.Is this a repair to an existing'yell: DYes or lii7i�0
0,this is a repair,fill out bimna+'veil cant uctiot+infornation and explain the nanwe of the 23.Site diagram or additional well details:
repair under#21 remarks section or on the back of thisfornt. You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
8.Number of wells constructed:
For multiple it jection or non-water supply wells ONLY with the same constntctiun,you can 24.Submittal Instructions:
submit one form. i
��� (ft.) 24n. For All Wells: Submit this farm within 30 days of completion of well
9.Total well depth below land surface: construction to the following:
For multiple wells list all depths ijdifferent(example-3 t0100'and 3 rt 1001
02 s � (ft) Division of Water Quality,information Processing Unit,
10.Static water level below top of casing: 1617 Ninil Service Center,Raleigh,NC 27699-1617
lfunter level is above casing.use-+"
24b.For Iniecdon Wells: In addition to sending the form to the address in 24a
11.Borehole diameter: (in.) above, also submit a copy of this form within 30 days of completion of well
12.Well construction method:
/\0 construction to the following:
�.�� _
(i.e.auger,ratan,cable,direct push,etc.) Division of Water Quality,Underground injection Control Program,
1636'Mail Service Center,Raleigh,NC 27699-1636
13.FOR WATER SUPPLY WELLS ONLY:
�., 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) 2 lhethod of test: T7 the address(es) above, also submit one copy of this form within 30 days of
.n completion of well construction to the county health department of the county
13b.Disinfection type
Revised Jan.
: T Amount: where constructed.
n-..----,-ranviv,mnene and Natural Resources-Division ofWater Ouality