GW1-2021-00065_Well Construction - GW1_20211109

t IIt res VII
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
-14.WATER ZONM
Z, -Wall CanGzctorNeme
FROM TO DSSC111pT70N
4t lrewdiConrmatorcxti&oaeoaxumtrer �}' la.OUrMt rmotn' we oxLlClBg ueawe
FROM T6 DIAMETER TMCKNESS I MATERIAL
In.
Company Name 'c
16.IPIlVSItCASINGORTUBING lbern>sidosedloo
2.Well Construction Permit : FROM I TO I DIAM EM I TtI CKMRSS IMAThs'niAL
bisl all applicable well Construction permits(Le.UIC,Caung,,Sm.VarlanCe,ere.) it. in.
3.Well Use(checkwell use): tt. & iht.
Water Supply wen: .mom
TO D sLOTg= I Traci mss I MATIMUL
Agricultural Municipal/Public 0 ft.
Geother nal(Heating/Cooling Supply) Wesidential Water Supply(single)
Indush'Ia1/Commercial DResidentiai Water Supply(shared) 1R GROUT
Itri Dn FROM TO MATERIAL METHOD&AMOUNT
Non-Water Supply Well: ft. it. rp
_ Monitoring _ Recoveryft. & /-
Wection Well: f�
AI
uifer Recharge Groundwater Remediation
19:SAND/GRAMM PACK a licable
uifer Storage and Recovery SalinityBarrier FROM To MAT1r.RIAL EPLACIiaN MKMOD
uifer Test OStormwaterDrainage ft. ft.perimeutal Tcohnology Subsidence Control ft. ft.
othermal(Closed Loop) ElTrac er 2k DRILLING LOG attach additional sheets Fothermal eatin Caolin Return Other lain undo#21 Remarks FROM TO DESCRIPTION rotor ftn sdvmdc
( DfL ft. i
4.Date Well(s)Completed: /D/y-2 WeD ID>it Z 1 72 ft-
So.Well Location: ft. it.
to* ft. ft.
Facility/Owner�Na a Facility W#(if applicable) ft. f
ft. ft. 02
Physical Address.City,and Zip ft• ft.
PG 21.It8MARss V MR SECTION
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
ONO field,one latllong is sufficient) 22.Ce mti
6.Is(are)the wells) rmanent or OTemporary Qof Certifies we or nary
By signing this form.I hereby coo that the wfl(s)tvar(were)eonmucted in accombnce
7.Is this a repair to an existing well: [3Yes or o %vidi 15A NCAC 02C A100 or 15ANCAC 02C.0200 Well Construction Standards and thin a
If this is a repair,ftll out knom well conamcdon injormarion and explain the nature of the copy of this record has been provided to the well owner.
repair wider 921 remarks section or on the back of tbisfinn. 23.Site diagram oradaiti well delays:
S.For GeoprobeiDPT or Closed-Loop Geothermal Wells having the same You may use the back o page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction det9s:':Y_ also attaeb additional pages if necessary.
drilled: a,f
9.Total well depth below land surface: -�� (R.) 24a.For All Willi:-&9,Submit this form whthhD
For multiple wefts list dl depths if different(example-3Q200'and 2®100) y s days of completion of well
/ construction to the followtDS: r r
10.Static water level below to of easing: :
Pt (ft•) Division of Water Resources Info rtatton Pmtxssiag Unit,
If water level Is above casing,use"+" 1617 MainSe�vke Center,Raleigh}NC 27699-1617
11.Borehole diameter: an.) K
24b.J%r InieeSon WeDs�In addition to sending the form to the address in 24a
,(f above,also submit onp copy of this form1within 30 days of completion of well
U.Well contraction method: (iGe r construction to the following
(Le•augey rotary,cable.direct push,ft)
Division of Water Resources,Undergroumd 1bdecKon Control Pro,gran,,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699.1636
13a.Yield(gpm) Method of be.4i3 AG al k 24c.For Water SrmDltr&Iniecdou Wells: In addition to sending the farm to
/,, the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:�,tL Amounts A completion of well construction to the county health department of the county
where—1-tracted.
Form GW-1 North Carolina Department ofMwiroamentei Quality-Division ofwaterResourcce
Revised 2 22 2016