GW1-2021-02808_Well Construction - GW1_20211118

...... ..v�wti�a��,11V1v Kn•e.uxultr<W 11 For Internal Use Only: -- -
1.Well Contractor Info tion:
P�VLoc�hg(�` 14.weATExzoN>as
Well Contractor•Name f/ FROM To DESCRIPTION
you 3 -'A 10 ft. 1 C PM
NC Well Contractor Certification Numb" (q j ft jq? ft SGPM
-IUERCTNG for mnititosed;wensRTIt ifn ucmhy& O�6Dis Well P�)II(N D[AMETER TFUCKNESS MATERIAL
Company Name / 'f"1 ft ti: in. spvzl IRL
Q ;16.:INNEIt C p'G ORTUSING( thermal eloseddoo 2.Well Construcdou Permit#. ' g� 17 FROM To DFAbtETER TaiC d,400 MATERIAL
List atl applicable star/construction pernats(Le UIG CoUnW,State,Variance,etc.) ff. ft in.
3.Wl U Use(cheel;WeIl use): ft in.
Water Supply Well: 1,7:SCREEN;
-Agricultural PROM TO DIAMETIER sLorSIZE x>ncra�ss MATERIAL
ffK
�Municrpai/Pnblic fr. ft fn.
Geothermal(Heating/Cooling Supply) idential Water Supply(single)
tt ft. in.
Industtial/Commcrcial
— QlResidem6al Water Supply(shared) iti:GROUT.IrEigat -
.o FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 pr 20 R
Monitoring Recov 111 e.
R ft
Infection Well:
-'Aquifer Recharge E3Groundwater Remediation fL &
Aquifer Storage and Recovery DSalinity Barrier SAN!)1GRAVEL-PACI{`(if
FROM TO MATERIAL EMPLACEnIENT tKETHOD
Aquifer Test OStormwater Drainage ft ft
Experimental Technology DSubsidence Control ft. —ft.
Geothermal(Closed Loop) attaeb
Tracer 20:DItII LINI':f.OG additlenal sheets iineeessa
Geothermal(Heating(Cooling Retmm) Other( lain under#21 Remarks) I FROM TO DESCRIPTION caior,hardness,sollfmck rain s etc.1
n it. �• .I
4.Date Well(s)Completed: i - 10- 21 W.01D# Q 4� tt it
C�AC ON . L
Sa.Well Location: 5 it �Osft. Q
17elggdo D ft. Job :.
FacilitylOwncrNamo Facility ID#(ifappflcable) Il�o fI '
t/A !
ckc fa z from 327 b ey>-f C-141 e/Prn t Grepk 28GG3 / ft. / ft.
Physical address,Cary,and zip 6k , DD
All
eaJ>Un 301 IG i5173 21;ItEMP,RK5
County Parcel Identification No.(PIN) 20
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: /1n
(if well.field,one laf/loag issuffcient) 22.Certification: ` �9NPRCESSiNG 31G,5o46 N . 3a��i/ W ,�..�� uNr
I- i0-zi
6.Is(are)the well(s)QPernaanent or 0TeMp0rHry Signature ofCertifiedwell i Date
iiy signing this form,1 hereby cerfy that the urll(xi rws(were;constructed n accordance
T.Is this a repair to an existing well: Yes or ONO with 15A NCAC 01C.0100 or 15A NCAC 02C.0100 FVeld Consinrction Standards and chat a
ylhis it a repair fill ll out known well construction information and explain the nature ofthe copy oflhis record has been provided to the wrllmwer.
repair under#21 remarks section or on the back ofthisform.
23.Site diagram or additional well details:
8.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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ��, (ft) 24a. For All Wells: Submit this foam within 30 days of completion of well
For multiple wetlslirtall depths ifdifferem(example-3@ZOQ'mul 2(aj 1001
construction to the following:
10.Static water level below top of casing: (ft) Division of Water Resources
1f writer level is above casing„we"+" ,Information Processing Unit,
1/� 1617.Mail Service Center,Raleigh,NC 276"-1617
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form-to the address in 24a
12.Well construction method: 1 t RO'ar(t above,also submit one copy of,this form within 30 days of completion of well
0-e.anger,rotary.cable,direct push,etc) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resowrces,Underground Tnlection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a Yield(gpm) (7 Method of test: _ 24c.For Water Supply&Inlection Wells. In addition to sending the form to
I3b.Disinfection e-Edt� the addresses) above, also submit one copy of this form within 30 days of
typ • Amount: completion of well constructionu to the county health department of the county
where constructed.
Font GV✓-1 North Carolina Depa[trnent of Environmental Quality-Divisionof Water Resoun?es
Revised 2-22 2016