GW1-2021-00064_Well Construction - GW1_20211109

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WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Wen Contractor Information: .ryl
cXJYvr� 6&edit) la WATER ZONES
Well Contractor Name PROM TO DIISCRIPTION
ft, ft.
NC Well ContrvotorCertlfia ti—N.-h -.- rma walla R iteaDle
FROM TO DIAMETER MCKNM I MATERIAL
Company Name 413e,2
16.HMR CASING OR TUBINGUeothar=d closed-loop)
2.Well ConstrdWon Permit : FROM TO DIAMETER TMCKNESS MATERIAL
List all applicable well construction permits(ix-UIC,County,State,Variance,etc-)
3.Well Use(check well use): ft- ft. In
Water Sa :17.seREEN
PPlY Well: FROM TO I DiAMiTER I sL0'r st2E I TMCBNM I MATERIAL
Agricultural E3M oipal/Public O FL rL �;n.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) h- g, in.
Industrial/Commercial E)Residentiai Water Supply(shared) M GROUT t
hri ation FROM TO MATERIAL FJNPLACEMBIVTMETHODetAMOtINT
[Aquifer
ater Supply Well: ft. /r
toring Recovery ft. &
n Well:
ft. it.
fer Reclazge �Groundwaber Remediat n' 19 gppD/GRAVEIsEer Storage and Recovery 13Salinity Barrier x FROM TO MATERIAL EMPLACEMENTMEMOD
Test [3Stormwater Drainageimental Technology Subsidence Comroi ft. ft.ermal(Closed Loop) Tracer 20.DRII.LiNG'LOG attach additional sheets ireermal Heatin Coolin Return Other(explain under#21 Remarks FRotvl TO DESCRIPTION rotor, aotl/rodr ate
4.Date Well(s)Completed:./0 2 Well 1D#�3ifn 2`7
Sa.Well Location: /
Ft. ft.
Facility/Owner Name Facility MA(if applicable) ft. ft.
Physical Address.(Sty.and Zip ft' ft
21.RENIAR1i9. ..+ ;
PGrSDr, I `INFORMATinm
County Parcel Identification No.(pK
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees: '
(ifwell field,one rat/long is sufficient) 27J
w [ ;:
te
6.Is(are)the well(S) rmanent. or Temporary s;goatu f Cemfied Well Contract Dak
�� By signing this form,l hereby certify that the;weil(s)w (were)constructed in accordmrce
7.Is this a repair to an existing well: Dyes or Ei�I f< with 15ANCAC 02C.0100 or 15A NCAC 026.000 Well Construction Standards and that a
If this is a repair,fill out!crown well construction Information and explain the nature of the _Py of this record has been provided to d4WI owner.
repair under#11 renwh section or on the back of this form.
23.Site diagram c atltliholgl0 well details:
` You may use the back of this a to provide additional well site details or well
8.For GeoprobelDPT or Closed-Loop Geothermal Wells having the'seme,�:> y p>�
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells + Onsllucdon details..You may also attach additional pages if necessary. J
drilled: SUBMITTAL MMUCTIONS
9.Total well depth below land surface: Z t� (ft-) Z4a.For All Welled Submit this form within 30 days of completion of well
For multiple wells list all depths if different(emmple-3Qa 200'and 2®100) ;.,. COnsttuction to the following
10.Static water level below top of casing: 2 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699.1617
11.Borehole diameter. / (in) 241{For Injection Wells: In addition to sending the form to the address in 24a
/J above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: � � construction to the following
(Le.au8e,rotary,cable,direct posh,etc.) R,.. . i
DfiVl`sion of Water Resources,Underground Netuion Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail SaMce Center,Raleigh,NC 276994636
13a.Yield(gpm) Method of test 24c.For Water 3np11y&Injection Welts: In addition t0 sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: T Amount: 11 gk%&,%�, e�i completion of well construction tb the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of water Resourws Revised 2-22-2016