GW1-2021-00559_Well Construction - GW1_20210324

RECEIVED
WELL CONSTRUCTION RECORD MAR 2 4 20 orbrternal Use ONLY:
m
This form can be used for single or dlif lc wells
1.Well Contractor information: ) C �( r 3�7�0,f11,,Process i
( (444•S U ��b1 Sector mo'TERIZONES pESCBIrnoN
Well Connor Name R ft O /
A033 • �t636 R ft
Number i5.OUTER CASING for mdUMLI wens OA LINER if• Enbie
NC Well �am��� 1W le 1 L — °R� TO DIAMETER TnIC'IQiFSS MAT P.
D
iJ♦ /h K ft / is /�
Company Name Is.INNER CASING OR TUBING eoaermd<ImedAoo
� ��� ` 20a6 PIIpM R Tp K DWMEfE0. THICKNESS MATERAAI.
2.Well Construction Permit N: II — in.
Liarail applicable well permit,(te.Co ry,Stare. Vananre,Injemian,etc.) ft & in
3.Well Use(check well use): 17.SCREEN
Water Supply Wcll: rROM TO DIAMEIf.R SIAT SIZE TIIICKNid4 MATERIAL
D.
ft
DAgricultural CMunicipal/Public
ss '' R
CGeothermal(Heating/Cooling Supply) BResidrntal Wa[er Supply(single) fL In
Clndusnial/Commercial OResidential Water Supply(shared) I&GROUT
PROM TO I MATERIAL I EMPLACEMENT MCITIODR AMOUNT
Obri 'on oA' 6 ft PN
Non-Water Supply Well: R R
OMonitoring ORccovery,
R ft.Injection Well:
OAquifer Recharge 0(imundwater Remediation 19.SAND/GRAVEL PACK(if sBEhLcbkl
PROM TO MATPRIAL EMPIACEMErfI'METROD
❑Aquifer Storage and Recovery OSalinity Barrier R R
OAquifer Test OStormwater Drainage R R
OFxperimental Technology CSubsidence Control I0.DRILLING LAG(smach additional sh«a if nests,,
OfiNthermal(Closed Loop) 07fraeer PROM TO A DESCRIPTION color,Aaraa aNVra4 airs tar.
OCmithermal(Heating/CoolingReform) Cotter mx lain under N21 Remarks) d R U ft f (� I
�7 R ' fL Qwiv V p4e
4.Date Well(s)Completed�)"Or, Well WIN R IL
5a.Well Location: 1 K 2
IL
z'.
Fecibty/Owrrcr Name Facility,lDa(if applicable) ft AG R
l rP a RJ 126
fL R
Phys/�'e�s\1\Address,City,W Zip 21.R6DMFS
Can, Parcel Identification No.(PIN)
5b.Latitude and Longitude in degmes/minutes/seconds or decimal degrees: 22.Certification:
(if well field,am ledlong is sufficient)
34 93 .z) d4 N 261.19 Wdvd
�� a of Certified Well Colossians Data
6.Is(are)the weil(s): 614.ne st or OTemp irary By arguing this Jmm,/hereby cert6 that the well(a)was(were)constructed in accardonm
with 15A NCAC 02C.0100 or IJA NCAC 02C.0200 Well Connotation Standards and that a
7.Is this a repair to an existing well: Oyes or HNo copy ofthis record has been provided to the well owner.
Orrin,is a repair,fill out Mown well o vuma non information and explain the none of the 23 Site diagram or additional well details:
repair under 421 remark,secoon or on the back ofdasJorm. You may use the back of this page in provide additional well site details or Well
S.Number of wells constructed: I construction details. You may also attach additional pages if necessary.
Formultiple injection or non-water supply wells ONLYwith thesto a Construction,you can SUBMITTAL INSTUCT IONS
submit one form.
9.Total well depth below land surface: 00 (ft.) 24a. For AR Wells: Submit this form within 30 days of completion of well
For mulople wells too all depths Jdifferem(example-3@200'and2@1100') construction to the following:
10.Static water level below tap of casing: 35 (ft) Division of Water Resources,Information Processing Unit,
Orions,level is shave rasing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
1
11.Borehole diameter: y /g (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
/�
p 24a above, also submit a copy of this form within 30 days of completion of Well
12.Well construction method: A/ R construction to the fallowing:
(i.e.au !Dory bin,direst push,eta.) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
S �, Q 21c.For Water Supply&Injection Wells:
13s.Yield(gpm) �J Method
of test
Also submit one copy of this form within 30 days of completion of
136.Disinfection type: NTH AmoaaC '/UT well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Denaturant ofEnvironment and Natural Resources-Division of Water Resources Revised August 2013