GW1-2021-00542_Well Construction - GW1_20211222

!III Ik I"VI111
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
�D�tw. �t1fl�ts� 14.WATER ZONES .
Well Contractor Name FROM TO DESCRIPTION
3D2�-/3 g`��• 4 i o'er'
M &
NC Well Contractor Certification Number 15.OUTER CASIIVG' i mumsased*e OA LENER Ira ncable
/ u p //S /�L, FROM TO DIAMETER THIOCNESS MATERIAL
�fy� cy 1 ft. I1 ft. in. [ le-
Company Name p / ` 16.INNERCASING OR TUBING eotherinai closed•loo
2,Well CDnShWti0n Pe',nit#: 1 77 `�I FROM I To I M MErER I TlaCKNIM MAIMAL
List all applicable well construction permits(ix.61C,Co*,,State,Variance,etc.)
3.8Vell Use(check well use): ft. ft.
Water Supply Well: .17.SCREEN
Agricultural FROM ' TO DIAMETER SLOTSI7)a THICKNESS MATERIAL
.t
Municipal/Public 0 ft. ft, in.
Geothermal(Ijeating/Cooling Supply) fL ft, in.
I strial/Comiriercial OResidential Water Supply(shaMd) I&GROiPr
'on FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft w 1Ie
Monitoring 011ccovery fL ft.
Injection Well:
EL ft.
I_.Aquifer Recharge ElGroundwater Remediation 19 SAND/GRAVELPACH if licable "
Aquifer Storage and Recovery [33almity Barrier . FROM TO I MATERIAL EMPLACEMENT-
-Aquifer Test OStorinwater Drainage ft. M
Experimental Technology [3Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal eating(Coolin Return) MOther lain under#21 Remarks FROM TO DESCREMON color,Hardness,-Wlmk sire,ete.
$. it.
4.Date Well(s)Completed: •j Wen M# 7
ft• r ft.
Sa.Well Location:
M ft.
nULe"
Faclity/ wner Name Facility lD#(if applicable) ft. fL
W- j SDIwy- Alt ft. ft rj ;
Physical Address,City,and Zip ft. M
��1HS lar1 21.REAUM I F 1 2 y 7r,91
County Pamel.IdenlifiationNo.MM
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees: '
(ifwell field,one lat/long is sufficient)
22.Certificati
3��3�'�/7. 00 -v 7d'/f-13G.'�70y'' w2 "/ 4f -2/
6.1s(are)the well(s)QOermanent or OTempiarary . ign of Certified Well C&tiador Date
By signing this farm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an eidsting well: nYes or �o with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200,hell Construction Standards and that a
If this is a repair,ft11 out latown well construction iq formation and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 renwrks 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 I GW-1 is needed. Indicate TOTAL NUM3ER of wells construction details. You may also attach additional pages if necessary.
drilled: n scrglvaz-rat_IIvsrRLrCTroNs
9.Total well depth below land surface: 75 (fQ 24a.For All Wells: Submit this font within 30 days of completion of well
For multiple wells list all depths if dWerent(example-3©200'and 22@100') construction to the following:
10.Static water level below top of casing: 20 00 Division of Water Resources,Information Processing Unit,
If water lever is above casing,use^+- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter._11 . (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: " above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct puush,sk etc.) construction to the following:
Division of Water Resources.Underg..nuna Injection Cont-1 P—Wo M7
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2 McMOd of test» �C For Water Supply&Iniection 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: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016