GW1-2021-01102_Well Construction - GW1_20210322

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
1}1yl �� 150Y) 14.WATE ZONES
EROM TO I DF RIMON
Well Con
tractor n
Name .
tfl.
o LW r_ 43�n �f n. h
NC Well Contract.,Cenificadon Number 15.OUTER CASING(for mufti-cased wells)OR LINER(I a Me)
1\lri,:501\� Qti (i�Zl �� t n R =f)L TROM fl ro DfAh4-TER in. rmcK.NEs SureRw.
Conpany Name I&INNER CASING OR TUBING( dosed-1 )
2.Well Construction Permit IT: FROM 7D DIAMETER .,isNM MATERIAL
Iln all opplicnble nett consrn,rri.n proms fie.WC.Court'.S"a"Va.",e,ct h• fl. ia'
3.Well Use(check well use): n' n. in
Water Supply Well: 17.SCREEN
PPY FROM I TO I DUA1H1'ER I SLOTSIZE TfIICIUN SS FAMITUAL
Agricultural QMunicipal/Public ft. ft. in.
Geothermal(Healine/Cooling Supply) ���......,©...ff{Residential Water Supply(single) R fL in.
lndustrialiCommercial Residential Water Supply(shared) Ia GROUT
Irrigation FRO\I lT1 SfAlERL\L EMPIACEME7A\ 110D&,%IOtR,T
Non-Water Supply Well: Q fl. (�t fl' G v I
Monitoring Recovery
Injection Well:
ft R.
Aquifer Recharge ©Groundwater Remediation
19.SAND/GRAVEL PACK(ifa Ne)
Aquifer Storage and Recovery Salinity Barrier FROM ro )fATEYI.ti. ENPLAL'E\IHiT ME 01)
Aquifer Test QStmmwater Drainage
Experimental Technology QSubsidence Control fl. n.
Geothermal(Closed Loop) QTracer 20.DRILLING LOG(attach additional sheets if )
FRO\I TO DE5(WIPr10N bola,.hardnea.ruYr l nsi terr.)
Geothermal(Heating/Conlin.Rehm) Other(explain under Ik21 Remarks) ) n 1 n.
4.Date Well(s)Compieted:p{r-1 9-2) Well ID# fl. �50I fl
5a.Well Location: t 11. ft
�Facility.Owner Nion: �1 Facility ID#(if applicable) fl. n. \.
�rs it Ft 1 py t . 1 oam i—, N C . n. n.
Phweril Address.City,and Zip IT.
n. y
21.`R,EMARKS r
County Parcel ldcmificatbn No.(PIN) YAlp ` •\�
5b.Latitude and longitude in degrees/minuteslsecends or decimal degrees:
(if well field.one laViong is sufficient) 22.Certification: �.•'
N W \ L
6.Ls(are)the w'e6(s)i(Permanent or QTemporary nature of Certified WellContractor Date
7� 1��1rr...yyyy Br signing dru form/hereby ,nif.,thin,he siren/fist ems luerr!cnnnnmed in rscundnnre
7.Is this a repair to an existing well: QYes or UNo r'h 15A NCAC 1/2C.0100 nr 15A NCAC 02C.0200 Well C my nutian Smrrdooh and that a
If this is a repair.fell our knnnn yell mnrrmoinn wfimrrnlinn a c pinln the nrnurr of 0., r upy of this record has been pmeided In the urll awry.
repair under#21 rvouab sernn..or on die book,,f uhh funs.
23.Site diagram or additional well details:
8.For Creoprobe/DPT or Closed-Loop Geothermml Wells having the same You may use the back of this page to provide additional well site details or well
construction-only I GW-I 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: ( h W (f-) 24a. For All Wells: Submit this form within 30 days of completion of well
F.rvnu/riple i rlh ho oll dga/u if diffoea,fem,nplr-3(d 2Ao'and 2 i BID') construction to the followine'
10.Static rater level below lop of®sing: (DA1 (fit) Division of Water Resources,Information Processing Unit,
/)navr level s nb„yr wring.use" 1617 Mail Service Center,Raleigh,NC 27699-1617
It.Borehole diameter: I n (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
�i y above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Vt 1 IZ (7 l 1 construction to the following:
(i.e.auger.rotary,cable,direct push.eta.) l
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699.1636
132.Yield(gpm) 15 Method of test: 1)Z 24c. For Water SuoDly& Injection Wells: In addition to sending the form to
the address(es) above. also submit one copy of this forth within 30 days of
13b.Disinfection type:WAn Annuitant: completion of well construction to the county health department of the county
where constructed.
Form GW-I Nonh C=Iina Dcpanment of Eii%imn=nwl Quality-Division of Water Resources Revised 1 11-101 h