GW1-2021-00563_Well Construction - GW1_20211222

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
)oft 14.WATERZ40NES
Well ContractorName FROM I TO DESCREMON
7A r &ft
�b
NC Wen Conb=tor Cedwantwn Nunihm
I e
FROM TO DIAU�TSR THICKNESS I MATERIAt,
CompanyNama
I&INNER CASING OR TUBING closed-lowl
2.Well Construction Permit : 1T 0 "( FROM ITO I DIAM91zx TBICRNBSS I MATERIAL
List all applio2ble well mnomcdon permits(i.e-UIC,Cow4%State,Parlance,etc.) ft. R•
i
3.Well Use(check well on): R• I
Water Supply Well-. 1�=se[tsltnr
FROM To DIAMETBR SLOT MATERIAL
Agricultural ElMunicipaMblic p ft. & in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) `
fL ft. In. 1
Industrial/Commercial DRWdendal Water Supply(shared) I&GROUT
1
hTigation FROM TO MATERIAL EMNACEMENTMSPHOD&AMOi)NT
Non•Water Supply Wen: O ft- ff- VuAPMAA ScrOA9
._ Monitoring g•
Infection Well.,
Aquifer Recharge 130roundwater Relmediation ft. (L
19 sA1VD/Gum PACK firu.N.1 .
Aquifer Storage and Recovery 13SalinityBarricr FROM I TO I MATERIAL 13MtR.ACBM@PrMMOD
Aquifer Test OStonnwaW Drainage ft. I K• I
Experimental Technology DSubsidencr Control ft. I & 1 {
Geothermal(Closed Loop) E)Tracer 24.DRMMGLOG attach additional shaeft if
FROM TO DESCRIPTION color, aoii ;;k-
Geothermal ea' Conlin Return Other(explain under#21 Remarim) &
4.Date Wells)Coatpteted: Well W# e• tt• �OC 1C
5a.Well Location: R' ft.
�,irPrxa P, '�9 S� ft• ft.
Facility/OwnerN a Facility ID#(ifappIi-ble) % ft. u x ,'•
D a ft. ft.
Physical address,City,and tip ft• R•
,Q n 21.REMARKS
County Parcel Identification No.(PN
5b.Lattmde and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one llaaUlotng1 is sufficient) C� / 22.Certification:
L. L"I o`7 3S2 N - 7� . OS b� ( W
6.Is(am)the well(s) Permanent or Memporary S' ofCortffied WaIrConl=tor Date
By signing this form.I hereby certify that the weB(s)was(were)constructed in acemdmree
7.Is this a repair to an eslsting well: E3Yes or o with 15ANCAC 02C A100 or ISANCAC 02C A200 Well Construction Standards and that a
ff this is a repair.fill out known well construction in/Wmadon espial,the nature of the ropy of this word has been provided to the well anmer.
repair under#21 remarks section or on the had of this form. 23.Site diagram or additional well details:
8.Fbr GeoprobeMPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
oonstruction,only 1 GW-1 is needed. Indicate TOTAL NUU BER of wells construction details—You may also attach additional pages if necessary.
drilled: nA citllltln7'rAL DVSTRIICTIONS
9.Total well depth below land surface: �t t� (R-) 24a.For Ali Welts: Submit this form within 30 days of completion of well
For multiple wells fist all depths ifdifferent(aaWle-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: ^ (ft.) Division of Water Resources,Infarmatloa Praccesing Unit,
If water level is above casing,use"+" 1617 Mail Servicei Center,Raleigh,NC 27699-1617
il.Borehole diameter. 16 A
r� (in.) 24b.Eor Infection Wells: In addition to sending the form to the address in 24a
above,1Z.Well construction method: above,
D wl .alsosubmit one copy of this form within 30 days of completion of well
(i e•augcy-toy.cable direct p�etc)
construction to the following
DM&n of Water Reromtxw;Underground II1lectfon Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service!Center,Raleigh,NC 27699.1636
13a.Yield(gpm) Method of test: JOZ 24c.For Water Sagply&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: AnaonnR Q Z completion of well construction Ito the county health department of the county
where'consttucted.
Foam GW-1 North Carolina Department ofEavironmeutel Quality-Division of WatorResomixs Revised 2--92 2 0 1 6