GW1-2021-01026_Well Construction - GW1_20210305

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor lYformtion:
L TI`4B Y\ J eb S n1 le.WATER TONES
—1- J 1Q(, FROM
c ro DESLTIr110`!
Wcti Contractor N.�an: t1�r� x � 1'
/ �` —A r R R
NC Well Contractor Certification Number 15-DIRER CASING fr nsW-erN wei OA INNER
LA, / r n iel 1l l -)' 1 I L C:, , R R I Lp b. MATERIAI
Company Nrmc /�d /� 1/ IL INNER CASING OR TARING dmed4
2.Well C♦ppx[rnetloa Permit N:��� -1 1 PROM To mAMc1Ea TllleiO ass MA1.
Lin all applimble well emunvrnoa party!.(" UIC. nunry.State,Yonance.eMJ D- R' in.
R R la
3.well use(check well rase):
n.scREEN
Water Supply Well: FROM I TO I alAMerix I SIAT SIa I TRtcIDlEss MATERIAL
ClAgriculturel OMunicipal/Pubbc R R Is•
0Ocothermal(Healing/Cooling Supply) Oesid Ed Water Supply(single) R R la
OlndustdaUCarmtacial ❑Residential Wrier Supply(shared) ILGROUT
ElIm m []Wells>100000 GPD FROM ro MATERIAL I mM crM®'lr ETNODa AMOUNT
No -WnmrSupplyWell: O R 9 C) fL CM/o
OMmitortag OReswvery R R
1�R R R
OAquifa Recharge OCaoundwater Retnediation If,9AN111/CRAVEL PACK
[]Aquifer Stange and Recovery []Salinity Barrier FROM I m MATERIAL I0nP1AC0nNT METHOD
[]Aquifer Test OStorn"ter Drainage 'L R
DExperimenal Technology ❑Subsidence Control R R
OGmtheeml(Closed Loop) []Tracer 20.DRILLING L40G sWch Wdidemal shearK
PROM To DESCRIPTIONwlsr w lonk dr.
OGodhaml(Hahn aoliog Return) OOlher(ex lain under N2I Remarks) () R R D SO 1
4.Date Well(s)Capitulated: - e / WeI IDN D' O R G
Sa.Well Location: G R ..Sv R sli n
kgte�.r �e 71,c,rr, h�t�l� R R
Facility/Owner NanY "Facility IDN(ifapplicablc) D- 0 R T4llt �
-)C)s Pe fro n aV/ R R
Physical AAddre City,and Zip R R
/'f G n'k\ 21.REMARKS('
County ParailIdentification No.(PIN) ✓ GGI ar )r\ (,,; Sil
5b.Latitude sad bagitude in degrceslminutes/seeoads or deeiml degrees:
(if well field,one laulong a.,i ficcm) 22.Certification:
N W I GLL1�J� r3
L m(ara)the well(s): 9girmnenf or OTempwary Sigmaaue ofCatificd Weil otracmr Dace
� l!i-'Vnrg disforw.Ih� sfl'by cerUw the mitts)war(,wee)maoucmdu di accordance wi
7.Is this a repair to an existing well: OYm or a ISA NCAC 02C.0/00 or ISA NCAC 02C.0I00 Well Cownvnion Stud"and that a copy
If"u a repair.Jill our boanw wdlewnsvions i ftwoonarn aderplaw the samre ofthe ofdde nrord has Ampnwidd sa dr ndl ouwr.
repair under N21 rtwmkr remora or on 4,back ofthis forty.
23.Site diagram or additional well demur:
8.For Cmprobr/DPT or Closed-Loop Geothermal Wells having the sarne You my use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wens (suld'Sm Oren in Remarks Box).You my also attach additional pages if necessary.
drilled: ^�s 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: -LG (R) 3YbmD Nan GW-1 within 3e days otweR completion per the following:
wdriple welir lice all depth ifd�s(ersmple-3@200'and 2®/00'1
I&Static water level below top of wing: j (fL) 24a• For AD Wells: Original font to Division of Water Resources (DWR),
If water level:'above casing.uw'� Infarm Processing tion Unit,1617 MSC,Raleigh,NC 2 7699-161 7
11.Borehole diameter: (in.) 24b.For lslerdkon WeW:Copy to DWR Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well mustra th ctlon meod: R"fa f L/ z4e.Far WsM Sn and Geol6erml Return wells:Copy to the
(i.e.matter,roury,mbk,dived pink etc.) county mviroumenbl h t ot the county where instal
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Yrodudae over loOASE GPD:Copy to DWR,CCPCUA
C( / Permit Progam,1611 MSC,Ralcgb,NC 27699-1611
13s.Yield(gpm) '/,1 T Method of trot: �0 W
IJb.DWuleatlen type: is 1 1 Amouot:
North Carole°Dn;ammr of FavbavveoW Quality-Divium of Wrier Resources Rcvvad 642018