GW1-2021-01101_Well Construction - GW1_20210322

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
L Well Contractor Information:
J�M ES f4.WJAZONES
FROWell Crenuactor Name a,GWC Q464 n.
y1C Well Conlmctor Cenificauon((N1inat el{� 1f1 r(1 15.OUT
CASING(for multi-eared wells)OR LINER('d a � Bcahle)
U'%t b� Well U I`I l l f TO n DLi5 25 to TRICANE\S MA�
Company Name LD
16.INNER CASING OR TUBING( eothermal closed-too )
2.Well Construction Permit fl: O'er (Urfa FROM TO DIAMETER MCKNF_tiS \UTERIAL
G.n n11 npplieuhle will...... union..tire lie.UIC,Cnunn.smte.V"Ma".no.l ft. n. in.
3.Well Use(check well use):
Water Supply Well: 17.SCREEN
PP FRO\I I TO I OL\.yIETER SLAT SIZE TmCKI'ESS 11ATERWL
Agricultural QMunicipab Public n. n-
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fl it. is
IndustrialiCommercial QResidential Water Supply(shared) tR.GROUT
Irrinalion FRO\I TO AIATFRrAr EIrPLAI.M\IEsT AH71110D&Aslrlt'T
Non-Water Supply Well: R' 1 R' ray; ' U-BA
Monitoring Recovery n. ft.
I -'ion Well: n. n.
Ayuifer Recharge ©Groundwater Remediation
19.SAND/GRAVEL PACKIa We)
Aquifer Storage and Recover)' Salinity Barrier FRO\I TO )BIATERLM. EMPLACE%HNT]ILTIIOD
Aquifer Test QStormwater Drainage ❑. R.
Experimental Technology QSubsidence Control ft. n-
Geothermal(Closed Loop) QTracer 20.DRILLING LOG(amach additional sheets V )
FROM TO D13CR�1'ION IraMr,Mrdaea.sniamrar x,efel
Geuthennal(Healing/Cooling Return) r 1 Other(explain under#21 Remarks) n, I fl-
4.Date Well(s)Completed:�g- ,3_ Wen IDRCIX-IUr%'7 1 n. l n.
Sa.Well Location:
�^ t It. n.
RAW M
Faciliry Dwn Name 1 Fadlay lDa(ifxppl'x:sble) n. B.
011� FP�r\f\ � i�` CJRy �{4FLY1� NC.
nPhcsical Address.City,and Zip *NIAMKS
n. �
W 54�+gm35�49(D
►
Count, Parcel Identification Nu.iPIN)
5b.Latitude and longitude in degrees/minutes/semnds or decimal degrees:
of well field,rare Iavlong is suf eeno 22.Certification:
N W
6.Islam)Ore well(s) Permanent or QTemporary si_ atureof Cenitied Well Commnor m� c
8r ig++mg rhis hmn. I h,eeby eenif, rhnuhe,,Ah,)mu fveru rw+nm red in<oronlunre
7.Is this a repair to an existing well: []Yes or lfNo ,l5A NCAC 02C.0100 nr l5A,VCAC 02C.0200 1V II Cnnstmetinn.Sunmh,rds and rhar u
b rhis is a repair,fill nul loot rre11 enmmaninn infon.Linn +A it!e,pfnin the nnrure n(rhe +,...... dn,reonrd has hen,per,,ided m d,r yell corner.
relwir under=21 Lemons sectinr,or nn the back of rhiv frmn.
23.Site diagram or additional well details:
8.For Geoprobe/DPf or Closed-Loop Geothermal Wells having the same You may use the hack of this page to provide additional well site details or well
construction.only I GW-I is needed. Indicate TOTAL NUMBER of wells mnstruclion details. You may also anach additional pages if necessary
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3-I'W (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
Fnrnudtipfe melt,tin n11 depdrs if diferenr Iccample-3(a 200'rind 2(d.100') construction to the following:
10.Static water level below top of using-. Ub (tL) Division of Water Resources,Information Processing Unit,
/Jo mer level it nlanr,nsing.use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: LQ (in.) 24h.For Infection Wells: In addition to sending the form to the address in'-4a
��77 1- r t above. also submit one copy of this form within 30 days of completion of well
12.Wellmns ''fAttruction method: ►}I lk &A-Ag(S construction to the following:
,i.e.auger,mmrv,cable,direct push et,) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) LD Method of test: 4ilZ 24c• For Water Supply &Infection Wells: In addition to Sending the fort to
��.�ry the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: •1-LL�dL�J Amount- completion of well construction to the county health department of the county
where constructed.
Form GA-1 North Carolina Department of Ea,i......uilQuafit,-Division n(W,tcr Rea,urnes Revised' ` 1016