GW1-2021-01065_Well Construction - GW1_20210322

WELL CONSTRUCTION RECORD (GW-D For Internal Use Only.
1.Well 4 star InfprmaaJJtion:
_ U r✓ C C-t�-7 14.WATER ZONES
Well nct Nor m Nae
FROM TO DFSCRIPr10
y V/J�f�4 tt s
NC Well Co star Cc ion Number 15.OUTER CASING far magFoaed weW OR I.RIER
{ n Most TO D1AMErFA imCIQiFSS MA'FTRIAL
Co try Name
16.MNER CASHIGOR T(RING
2.Well Construction Permit#: PROM I TO 1 DUPIerPR rnuC P MATF,RIAL
Lill a!!applicable uell conshucnon permia/i.e.U1C.County,Slate.parlance.etc.) tt n. Is,
3.Well Use(check well use): R- f. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER aLOfSVE TWC6TtES5 MATHRIAL
Agrfculmml [)Mmaicipal/Public fL y vtt lu. s (/rJ 61`
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) FL I fL
Industnal/Cornmercial [)Residential Water Supply(shared) I&GROUT
-jinigation PROM TO NIATIERML EJIIPLACF.MENf METHOD A AMOO
Noo-Water Supply Well: n. R.
Monitoring DR=ovcry tt ft,
Injection Wel
R. ft.
Aquifer Rec ®Gmundwsler Reriediation
Aquila Stooge and overy [)Salim er mom I TO DfiGRAVEL PAS MA rwL RMPIA R TXr MRTRop
Aquifer Test Stormwata Drainage R- tt �2
Experimental Technology Subsidence Control R. tt
Geothemtal(Cho ) [)Tmc 20.DRILLING LAG launch additional sheets If
Geothemmf(Heatin Coolie Return) r3Other(ex Ire under#21 Remarks) FROM TO D►SCRIMON coClor mrvmek elr.
4.Date Well(s)Completed: Well ID# R' tt C L
D•
5 ell Location: tt ^ C9
Facility/Owa:r M.. WV P Facility lD#(if applicable) / EL
nq!d i�Y(�LP(l ll ( sti ;
Physical A City,and Zip 'it. ft
Mosli�
cowry Parcel Identification No.(PIN)
5b.Latitude and longitude in degreestedoutedseronds or detiptfd degrees:
((iiff�weD ficiidd,we lat/long is sufficient) 22.Certill '
31 N ltK' U� u 1 W ��� U
6.Ware)the well(s)UPermt scat or ®Temporary Sigm o Ccnificd Well Contractor Dare
By signing thin form,1 hereby certify Thal the"11(s)tear(were)conrlmeW in accordance
7.Is this a repair to an existing wen: [)Yes or No wish 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Controo rion SmMardr and due a
lfthis is a repair.fill out brown well conshsn tion information and explain the nature of the copy of hir record has been provided to the troll owner,
repair under#21 remarks section or on the back afthis farm
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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: �1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 00 242_ For All Wells: Submit this form within 30 days of completion of well
For mulfiple wells list all depths if different(erample-3(d 00'and 2�Ja 100') construction to the following:
10.Static water level below top of casing: / (ft.) Division of Water Resources,Information Processing Unit,
If,. rat lewd is above easing.use"1 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniecton Wells: In addition to sending the form to the address in 24a
��n ( above,also submit erne copy of this form within 30 days of completion of well
12 Wen construction method:�'"'V e �-' 4rl construction to the following:
(Le.auger,ro ury,cable,direm push,etc) r
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Man Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)�� Method of test: 24c.For Water Spooty& Injection Wells: In addition to sending the form to
L the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 1 C 11'-,-Y Amount: ' LL. completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Depannuent of Environmental Quality-Division of Water Resnurr s Revised 2-22-2016