GW1-2021-02699_Well Construction - GW1_20210811

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use only:
1.Well Contractor Information:
FGI
1C WATER ZONES
t 1 s`f it; ,� 0� �oM •� D;s�oH �n1f Well CorntactorName �'�Q ft / u by,C oa eS t 6M
e�1;0,11 , tL
NC R'Cff Contractor t deaHon Nambcr O� n 15.OUTER CASING or mnitl-weed wells)OR LINER f ilesble
�c�e���� FRoitr ft.
To � alAlueTgt� TRtclavEss ��T>;ItI,tL
Company Name 16.INNER CASING OR TtIHING eethermal closed
2.Well Construction Permit#: 's,�.._7._<7 A FROM TO I D/AMETEK I TIrICRNFSa I MATERIAL
lest all applicable well construction permits(i.e.UIG Cawny.State.VarIanM etc.) fL " In.
3.Well Use(check well use): ft I fL
Water Supply Well: FR SCREEN
FROM TO DIAMETER SLOT SI7� TffiCKNES5 MATERIAL
Agricultural ❑Mtmicipal/Public -T fL /GC it ¢ la O PVtr
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. % to
IndusaWCommercial []Residential Water Supply(shared) is.GROUT
- FROM I TO MATERIAL EMPLACEMENT AWMOD&AMOUNT
Non-Water Supply Well: C R a S it AhE lit v tK 'Poo PF—rj
Monitoring Recovery ft. r4 Pi
Injection Well: & ft
Aquifer Recharge C]Gmundwater Rentodiatiou 19.SAND/GRAVEL PACK able
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. 1/0 ft // V 'PO V'
Experimental Technology ❑Subsidence Control it ft �Si
4
Geothermal(Closed Loop) QTM= 20.DRILLING LOG attach additional sheets If necessary)
Geothermal(HC2ft CDobn Return) Other lain under#21 Remarks FROM I TO DESCRIPTION eolor,hardoem eoNroek type,arain etc.
0 'L to " Pt t Y.EA S#Nb
4.Date Well(s)Completed:7 o2r7—�1 Well ID# 10 f' 20 'L 4"1 Ct.R
Sa.Well Location: ZO ft 30 tL GtR*VEI. SgaO CZA
PGinikkl- SF�i.I fo CJ ft .5 S
Facility/O
�wnerName Facility lD#(ifapplicable) (G0 Z n D St�t.({7) SNP CLIH
1.a�lt PGi,�f�tal�). .i'..E� t�['fal�l &r. 279.-d.. . . 70 ft r 1.0 ft. S'41.[ Sore C.. Cc+4P-sE-
Pfi++ysical Address,City,and lap
�r
�440 W Ad 21.REMARKS
county Parcel Ideadfication No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tatilong is saf5cient) 22.Certification:
6.Is(am)the well(s)pPermauent or Temporary SigoaNre of Certified Well Contactor Date
By signing this farm,1 hereby certify that the tveil(s)was(were)eonstru ted in acwreance
7.Is this it repair to an existing well: Dyes or WNo with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Wen Construction Standards and that a
If this is a repair,fill out known well construction information nd explain the natum of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of thisform. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Genthermai Wells having the same You may use the back of this page to provide additional well site details or well
construction,only l GW-1 is needed. Indicate TOTAL NUMBER ofwells construction details. You may also attach additional pages if necessary.
drilled: SUR&RWALD(STRUCeTLONS.
9.Total well depth below land surface: /117 (ft-) 241L For All Wells: Submit this form within 30 days of completion of well
For multiple netts list all depths j(djfjerent(c=nple-3Q200'and 201005 construction to the following:
10.Static water level below top of casing: (tit) Division of Water Resources,Information Processing Unit,
ff water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter. —7 7/ (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.WeIl tvDshvctloa method: M rJ '%q Qy above,also submit one copy;of this foam within 30 days of completion of well
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Uadergr W Iajeetiea Coatrof Program,
FOR WATER SUPPLY WELLS ONLY: �i 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 O Method of test: A/V )E f/ 24c.For Water Smmly&Injection Wells: In addition to sending the form to
so 17 i o"\ i♦ PO CJi Lil Q( the address(es) shave, also submit'one copy of this form within 30 days of
13b.Disinfection type: Amount. 9 t) Z completion of well construction ion to the county health dipattment of the county
where constructed.
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Form GW-1 Nortb Carolina Department of Environmental Quality-Division of Watcr Resources Revised 2-22-2016