GW1-2021-00726_Well Construction - GW1_20210322

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
5 I�WNI °L� ai1�5p� 14.WATER TONES
c FROM I TO I DESCRIVRON
WeII Conaacmr Nana
f,C rt. n.
n. n.
VC\Yell Contractor Ccnification Numher 15.OUTER CASING(for malti-cased wells)OR LINER fda ' ble)
�� �n�, FROM TO DLta R T flcl hNIMS \L\TFRIAI.
I ( n. r n. in. ` Y
Company Name G 16.INNER CASING OR TUBING( talhermal chased-1 )
2.Well Construction Permit#:L�, CR J I FROM TO DI.NIEIgR TWCICIYF_ti'S )IATERIAL
List all npplimble yell construction perniirs lie_UIC,Cnumv.Stare. Variance.etc.)
3.Well Use(check well use): Of
17.SCREEN
Water Su ly Well:
PP FROM TO DlAslKER SLOTSIZ THICk} M SIATERGL
Agnculmml Municipal%Public D. R kL
Geothermal(Heating Cooling Supply) Vesidential Water Supply(single) n in
IndustrialiCommercial []Residential Water Supply(shared) I&GROUT
Irngation FRO)1 T(1 \IATFBIAL EMI'LACEMENTMmum&A\mCTT
Non-Water Supply Well: IJ rt. a n-
Monitoring Q Recovery n. n.
Injection Well:Recharge n. n.
Aquifer harge []Gmundwater Remedialion
19.SAND/GRAVEL PACK IRa bk)
Aquifer tom Sge and Recotery Salinity Barrier FROM TO T
)UTERL\L E\IPLACE.\IEYf)Ih'i110D
Aquifer Test []Slormwater Drainage n- R.
Experimental Technology Subsidence Control n. R
Geothermal(Closed Loop) []Tracer 20.DRILLING LOU(altacb additional sheets R )
6,taaR...aaart t,
Geothermalw(Heating/Cling RetuReturn) FROM TO DE IFTKVN(ew,r. azm di:.)
Other(explain under#21 Remarks)
4.Date Well(s)Completed: `_ Well ID# Ji
r n-
5a.Wed Location: `5 ft. 1 n
E l or n1p C n. It.
F duv Owner Nan l��/ .r NOW,ID#(if applient,10 n' h'
At�ilf b 1 �14 )PS�II«� 11C �219 n. n.
Physical Address,City.and Zipn. R.
21.REMARKS
Couniv Pnccl l&rtuficalion No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
lif well field,,,.lavloneLi,,(sut7wicnn 22.Certification:
6.Is(are)the well(s)4 ylPerman nt or QTemporary W Si )azure of Cm.fwd Well Con>�\� aill c
7� .igning chit Gran. I herrhr ,nii, that the ,,11 ) nccmdnnre
7.IS this a repair to an existing well: []Yes or o with IM NCAC 0_1C'01W ar 15A NGIC 02C.0200 tVrll 0"u n aimi.Smndnrdc and+hot u
1111is it a repair.fill nut R+mun a ell anmtrtmliun it f tan ..... +plain the nonce aG 1hr ,,p,of this r,nrd 1ms he en prnrided rn the yell nulmr.
repair under=21 r,.,the m,d 0 69609#9997q�.Egj &or additional well de&sS xe j 6£:7 L £ Der
S.For Ceoprobe1DPT or Closed-I C h 1 W Ile a inn the c me You may use the back of this page to provide additional well site details or well
conslmctiD�,only 1 GW-I is needed. Indical�� MBER of wells UmstmcDDn elat s. too may also attach adclumnal pages it neceaan.
drilled: SUBMITTAL INSTRUCTIONS �r{,(�
9.Total well depth a rtd sfifl 6fj UOIleJ0f7 1��Q (ft) 240K�PNiVells- Submit this form wiDIM' b days of��letion�}PtQll
Far++ndliple wNls tin all depths ifdii ferret frann9de.3(i2n0'ar d Trµ lot,) construction to the following:
i -
10.Static water level below top of casing: (R.) Division of Water Resources,Information Processing Unit,
If nmer Ierel is .. ore - 1617 Mail Service Center,Raleigh,NC MOR9HUB3,)Set
11.Borehole diameter: W (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
---> above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: conslmcoon to the following:
lie-auger.mug .cable.direct push etc) —I
Division o ate l n3echonZootro rgroun ram,
FOR WATER SUPPLY WELLS ONLY: Uel1636 Mad Service Center,Raleigh,NC 276"-1636
£960 L£9 9Z9 )`)Z
13a.Yield(gpm) � Method of I�—....—..�_ 2`c. For Water Supply & Iniectlon Wells: In addition to sending the form to
the addresses) above, also submit one co of this�form�w7iitt4in 30 days of
13b.Disinfection type: Amount: do;Bo-}xe.A 36 completion of well consinNUAS KAlm s+trpwscrrcnl� Q y
where constmcted.
I.GW-I NoM C:uolina Dcpnmcnt of Encirommntal Quality-Division of Water Rcsoumea Revised 2-1-1_-1016