GW1-2021-00716_Well Construction - GW1_20210322

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor I\nformation`:
\�fI)NA E5 Ll pn 1�- 1 �� 1 1.Sn i 14.WATER ZONES
IROAI I TO I DFSCRIPI'ION
Well Contractor Name n. n.
\yCarl L 14303 ` h. ft.
NC well Contmdnr Cenificatia`n lum,he[`r 15.OUTER CASING(for multi-cased welh)OR LINER fits Geable)
FROM TO DIAMETER TDICANF_SS sL\TFRIAL
Company Nmrre in.
11,h, \ 16.INNER CASING OR 7URI ( ihermW closed-too )
2.Well Construction Permit#:W a'<:�t'':/Y`1 f'1'1 FRO\I TO DIAMETER TRICKNF_SS I MATERIAI.
Gsr nfl npplirnhfe yell annsvuninn prnnirr he_UIC.Cnuno.9nre.Vrrinnre.ercl ff. I n. in,
3.WellUse(check well use): ft. I in.
Water$u 1•WeB: 17.SCREEN
PP J FROM TO DLNIEfER SLOT SIZE TRICRI E S MATERIAL
Agricultural ©Municipal/Public
Geothermal(Heating/Couling Supply) XResidential Water Supply(single) (L ❑, ia.
Industrial/Commercial ���[]Residential Water Supply(shared) 18.GROUT
Irrivalion FROM TO MATERIAL &'s1Pl.AC'E:MENT METHOD&A,MOUNT
Non-Water Supply Well: Aft. - t ft. (�(� GTaAf.1
Monitoring EIRecovery ft. f6
Injection Well:
n. n.
Aquifer Recharge ©Groundwater Remediation
19.SAND/GRAVEL PACK(tfa 'cable)
Aquifer Stomge and Recovery Salinity Barrier FROM TD AUTeauL E,%I . IIEW MMIOD
Aquifer Test C)Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control It. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
FRO\I TO DESCRIPTION real,,,6eNnecc saiYrrcY b �'ere,)
Geothermal(Heming/Cooling Return) Other(explain under#2I Remarks) 6IFt. A h.
Re CAPA)
4.Date Wellbs)Completed:i _[A-al Weu tD#W9C1a56u 'C1`7 7 4 n- g6l n-
t
5a.Well Location: 46 n• ft. 1 �`«"
�
n. n.fAi S , Ian � 0 d ,
Fneilio, 'rkr Namc Facility ID#(ifnpplk.1,k)
al 'cX Z rN1� olt 1AC o27SQUlp n ft. 6
/P�hysicra1 Address/.City.aid Zip �p�(�/n.��/R� pp�A((� Cl
( AIUW -' 14`-Z IUSJ[Y41r`7 WQ 21'REMARKS
County Parecl Identification No.(PIN) \•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if Well field-one)auto.._is su1T¢icnO 22.Certification:
ss�c-/�� N W
6.Is(are)the well(s)gfPermanent or OTemporary Si lamreof Certified Well Comnv]nr ran,
TlT� Br igning this Jnnn. !hereGr rerrifi'rha++he trelltrl n'as!n'rrel nnamrnrJ i..nr...... re
7.IS this a repair to an existing well: �YeS or No i ,/5A NCAC tP_C.OIW nr 15A NCAC 02C.02(ID Well Cnnsrn,ctinn SrorrJnots and rhnt a
Ifrhis is o rePoir.fill our kunun,rel!ranstmotinn infnnvndnn dm1 rrphun the.... njthe ,r to of this record has been provided in the yell owner.
,etwit under d2f nannrks.,ecrinn or nn the lxak of chic fnrnr
23.Site diagram or additional well details:
R.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. Indicale TOTAL NUMBER of wells construction details. You may also allach additional pages if necessary.
dulled: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ) AU (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
Fnr multiple orlLr list n0 depths ifJdrnnr lem^tp/e-3(u 20B'und2(gins') construction to the following:
y�py i
10.Static water level below top of rasing: (D.) Division of Water Resources,Information Processing Unit,
tf unrer/r,'r/I,rebore rasrm.use - 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: Ik (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
�1-' above, also submit one copy of this font within 30 days of completion of Well
12.Well construction method: 1}1�Z 1 construction to the folowine:
(i.c,auger,.rotary,cable.direct push etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699.1636
13a.Yield(gpm) 4U Method of test• A t )k 24c.For Water Supply &Injection Wells: In addition ro sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:61da 1115- Amount: S completion of well construction to the county health department of the county
where constructed.
Fom,GW-1 Nonh C: lina Dep:um>Lnr of Envin,ntmatai Quality-Division of Water Resources Re,i,ed 2-223016