GW1-2021-00814_Well Construction - GW1_20210215

WELL CONSTRUCTION RECORD(GW-I) For Internal Use Only:
I.W5ll Contractor Information:
_ Acdb-e 14.WATER TONES
Well CoMnccoir Nana FROM FD piSLWRION
R.
NC Well Contractor Cmifiration Number R
15.W L G c D°"'�"CASING r r pu m. KET weW oR LDVER
RAMErea TRICg1Bg MATrAl1AL
Co y Nemc
R R. la
f61NNER CASING OR 771RDVC Close"
2.WellConstructionsPermit#: / FROM TO InA.METER THICIDiESS b1ATER1A1.
Lar all applicable wMl w u"coon p,mu,(i.r.UIC.Caangt Sore, Variance.e11) R R in.
3.Well Use(check well use): 2 R. I&
Water Supply WeD: 17.SCREEN
FROM To DIAIRErER SLOT Sin THICKNESS MATERIAL OAgricultwal OMunicj bile R R I .
OGeothennal(Heating/Cooling Supply) E idrntiel Water Supply(single)
0hdu4ria1/C0mmercial pResidmtid Water Supply(shared) IL GROUT
Ohri 'on OWella>100,000 GPD FROM To MAnIUAL RM onagNrMENIOD aAMODNT
Noo-Water Supply Well:
OManitoring ORecovery R R
injection Well:
DA uifer Recharge R R
q rg OGroundwater Remediation
19.SANDIGRAVEL PACK
OAquifer Storage and Recovery OSelinity Barrier PROM TO T
h1ATERtAt. PSIr1.,ACOIDIT MEDMD
OAquifer Test ❑Stomlwater Drainage R R
OExperimenal Technology OSubsidcnce Control R R
OGeothermal(Closed Imp) OTracer 20.DRILLING LOG faftmem WdiW W shxn 1f
OGeothermal(HeatinglCoolin Return) OOlhtt(ex lain under 021 Remarks) most To DES RuermN �&muv w ere
R R
/ l C,
4.Date Well(s)Completed: — (il�d ' we"ID#
Sm.Well Location: V R G fL ri i I
yivaj, Corks IJR 30 fl C
Facility/Owrar Nana FacilitylD#(ifapplicablel ft. IL
?5 11J:llar� OR, R R
Physical Address.City,and Zip R R
lrrw^U� ��f 21.REMARKs
County Panel ldentific uoa No.(PIN) b'
5b.Latitude and longitude in degre s/miautes/seconds or decimal degrees:
(if well fold,ore IaVlong is suRcmno 22.Certification:
6.Isfam)the well(!): Errr— meet or OTemporary Sigpoue ofCMifad Well nustTor Date
Byr�ing lhitjorm./Femlycer*IhM Ike xel((s) ,su pecee)conueocuil m accordaitce with
7.Is thin a repair to as existing well: OYes or MNS � -( � )Jr4 NCAC 02C.0/00 or ISA NCAC 0IC.0200 Wril Conprucrion Slmdanta and ha a co.
If 1k.u a repo(,,fr(1 Hint k..well cnmavcoon infara I.a d.0oo,ilk name of the ofIhm record Am bew Provided m the well o~r.
repair under#21 remarla recnan or on[he back aflho form.
F�� 15
Z�11.Site diagram or additond well details:
S,For Geopmbe/DPT or Closed-Loop Geothermal Wells having the same You piny use the back of this page to provide additional well construction info
construction,only 1 GW-I is needed. indicate TOTAL NUMBER of wells (add Sce Over in Remarks Box).You may also atach additional pages if necessary.
drilled: I1. ' I . �{,� 24,sUBMFITAL INSTRUCTIONS
9.Total well depth below lands tfea �T /w+ 1 (2) Submit this GW-1 within 30 days of well completion r the
caw muf0ple wr((s(al all depdrr Jdigerenr(eramp/e-3(d�2lXI'ad 2®/!NY) Y P per following:
O 10. (R) mation Processi
24s. For All Wells: Original form to Division of Water Resources (DWR),
//waeerlm fer le lisaMwcasing,water level below lop of casing: Inforng Unit, 1617 MSC,Raleigh,NC 27699-1617
use '�
11.Borehole diamter. (in.) 24b.For Injection Wells:Copy to DWR Underground Injection Control(IUC)
Proluarn,1636 MSC,Raleigh,NC 27699-1636
IL Well construction method: 24e,For Water SopDly and Open-I.00D Cmtherml Return Wells:Copy to the
(ix.auger,rsauy,cable,direct paste etc.) coun mvllDnrllerlta ealih ty department o eomty where instilled
FOR WATER SUPPLY WELLS ONLY: / 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
-a I3a.Yield(gpm) / Method of test: ( � LA/ Permit Program, 1611 MSC.RaImgb.NC 27699-1611
13b.Disinfection type:Y N Apmunt: I I
Form G W-1 North Camlma Departmern of Envimnmanol Ousiity-Divining of W me Reanmces Revised 6-6-2018