GW1-2021-01088_Well Construction - GW1_20210305

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I,,
i P. lkar .�A Cobs 14.WATER ZONES
Well Contractor NName FROMP5.
11MCRIPTION
NC Well Contractor Certification Number '� 1OUTER CASING far mald-cased wells OR LINER bk
TO m.aMET it rmcloiF85 MATERIAL f7 Ciro n�- .0�r�I,( c 0 7
a. J a in - G Company sate
1 / / 16INNER CASING OR TUBING el
2.Well Construction Permit#: E ,� (J- U Cl I L) 1/3 FROM TO DIAMETER THICRNESS MATERIAL
LLst all applicable wrll co motion permits 0'.e UIC,County Stare. Variance,etc) ft. h. in.
3.Well Use(cheek well use): ft. m Im
Water Supply Well: 17.SCREEN
FROM lrl DIAMETER I SLOT&I!E I THICKNESS MATERAL
ElAgricultuml ❑MunicipaUPubfic fL fL
❑Geothermal(Heating/Ccoling Supply) EN esidential Water Supply(single) n.
❑lndustrial/Commercial ❑Residential Water Supply(shared) Ill.GROUT
❑Iniation ❑Wells>100,000 GPD FROM lY1 MATERIAL. EMPLACEMENT ETHOD@AMOUNT
Non-Water Supply Well: fL O R. c 1
❑Monitoring ❑Recovery IL 0.
Injection Well:
fL ft
Aquifer Recharge OGrolmdwater Remediation
am
❑A uifer Storage and Recovery OSahnj Barrier m SANDM.RTO PACK
9 �Y ty FROM TO MATERIAL EMPWCEMENr METHOD
OAquifer Test ❑Stormwater Drainage ft. R.
❑Experimental Technology ❑Subsidence Control ft. R.
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG armehaddldeaal sheers Bneeessa
OGeothermal(Hentin Coolin Return) GOther(explain under#21 Remarks) mom To OFWRIPTION ir rotor,hes Iur k q,,lost. mern a e
^ l 0 it. R. 'c ._SO;'
4.Date Well(s)Completed:. 'O 1 Well ID# H' fL G
1/0
5a.Well Location: - GrL O R. kqt
keG+o+� Vu Ynof, 5-0 a oS' ". GrU
Facility/Owner Name Facility ID#(ifapplicable) ft. 0.
q10 w NL- N ?
Physical Address,City,and Zip ft. R.
h4 S 14 21.REMARKS
County Parcel Identification Na.(PIN) `� C C, G � ,✓£ O
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lavlong is sufficient)
22.Certification:
N W
6.la(are)the well(&): Ofiermanent or ElTemporary Signature ofCenified Well Codiractor Date
By signing thisf rat,1 hereby certut,that the wrll(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MKo 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthrs is a repair,fill out known ar11 ennstrvefinn information and explain the nature afthe ofthis record has been provided to the writ owner.
repair under k21 remarks,vecdon m on the hack of this.�orm.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled" 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (fL)
For multiple its list all depdu,lfdifferem(example-3(a1100 and2 100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of using: 1� (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ijwater level is above casing,use"*"
Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24b.For Injection Wens:Copy to DWR,Underground Injection Control(IUC)
ff Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: G j4f l� 24c.For Water Supply and OpeD-Loop Gcotherntal Return Wells:Copy to the
(l.e.auger,mrsry,cable,direct pub,en:.) / county environmenml heap depamnrnt of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) 7 Method of test: G lr✓ Pcamt Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form G W-I North Carolina Depardm m of Environmental Quality-Division of W ater Resources Revised 6.6-201 g