GW1-2021-01025_Well Construction - GW1_20210305

J.L,i_L,, �t'(CDNSTRIITCTIOl\,T RE(<<(I',14 Ij) `;ni= l' For 1_ntemal Use Only:
ell,_on_ractor Information:
1 1411 L 60'Vt- 14.WATER ZONES ;
--- FROM TO DESCRIPTION
dell l ContractorNatneo - `` ft 5 T;Lft 3 ! Pin
J to w
1 `• -:II Contractor Certification Number
_ S.OUTER CASING(for mull(-cas ells)OR LINER(if applicable)
y.ll" _tl u� e/�/ ®���y (-I,4r ) �` a FROM TO DIAMETER THICIINESS MATERIAL
u'u v v o a — o fC. It. ln.
nr!•Iame ,�f/� 16.INNER CASING OR TUBYIVG eotherma[closed-loop)
. '.,:s'_^oi3siTaction Permit#: J" �/" FROM TO DIAMETER THICKINESS MATERIAL
;nrLcoble well construction permits(i.e.CIIC. 'bu;!v.State, Variaiwe,etc.)
rt. 96rt C./ f -r i,. S'0 7-I I P vc-
,' i_i;;_(claecic aye➢1 use):
ft. rt. in.
17.SCREEN
Well:
/ FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
I�'.;•'<-,uatral �llt r-zn ❑l'viuni.6�al/PubIic ft. ft. in.
i :sal(Heating/Cooling Supply) stdential Water Supply(single) tt ft. in•'
:.r:VConunercial ❑Residential Water Supply(shared) 19.GROUT
•�I__i__��it0i� ❑W�lls> 100,000•GPD FROM TO MATE/RIALJJ fEXPLACEMENT METHOD&AMOUNT
= Supply Well: -. _�_..,_ _� _�v�_.. it. tt. ,F . `TG 6J►Ap J C w1 e
it
.1!-:�tu: iing _� ❑recovcn,� ft. rt. t �`Af�! �,rnff ftin9 ��!'
Recharge ❑"non-,dwater Remediation
1-0.SAND/GRAVEL PACK(if a licabte
C Storage and Recovery ❑Salinici Bander FROM TO MATERIAL EMPLACEMENT METHOD
❑.-:siren Test ❑Sioma.vater Drainage
Tecbnology ❑Subsidence Control
�7+_c^tiF ,tal(Closed Loop} O T racer 20.DRILLING LOG(attach additional sheets if necessary
❑CeoEac,final(Heating/Cooling Retum) ❑Ofller(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
P) ft. C- ft.
n „=VVell(s)Completed: VVell MA6 0—✓6 I ft. )l ft. M-e / .SRO
Ve l Location: 336 ` S-117 � ft. i ft. m ed Any �c
ft. ft l
�y ty/•OwnerN me Facility ID#(ifapplicable)LOA
,:?.l -ddress,City,and Zip ft. rt. q
r
Q�I er 21.Pi(yrARKR
PareeI Identification No'(PIN)
"=etudL and longitude in degrees/minutes/seceulds or decimal degrees:
I!held,one ladlong is sufficient) 22.Certification:
��L
e'3 the well(s): �h�ermanent ar ❑TI_iupo',ary Si�atme of Certified Well Contractor Date
Bysigning thisfa•on,1 hereby cert�flat the wells)ryas(were)constructed in acca•dance with
repair to an existing well: ❑Iles tr' )�Nc 15A tVCAC 02C.0100 a)-I5ANCAC 02C.0200 Well Construction Standards and that a copy
e repair,fill out known well construction in foonolion and explain the nature of the of this record has been provided to the well orwner.
!!a er#21 rennarks section or on the back of this form.
23.Site diagram or additional well details:
.o:probe/DPT or Closed-Loop GeotherinaLl Wells having the same You may use the back of this page to provide additional well construction info
asii2tction,only l G V-1 is needed. Indicate:OTA-L NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
i IIr 24.SUBMITTAL INSTRUCTIONS
!L:cell depth below land surface: 9 U (ft.) Submit this GW'V-1 within 30 days of well completion per the following:
r!ulaple wells list all depths if dierent(ew nnple-3@200'and 2@100'1
/0 lls: Original form to Division of Water Resources (DWR),
0,c4.zidc ititer level below top of casing: (ft.)
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
:ram level is above casing,use"+" I
L ,i eiaole diameter: C. (iu3.) 24b.For Injection Wells: Copy to;DWR,Underground Injection Control(iUC)
Program,1636 MSC,Raleigh,NC 27699-1636
ell construction method: n R FR0111°UV'Y 24c.For Water Supply-and Open-Loop Geothermal Return Wells:Copy to the
auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
P_v-,/A,,ER SUPPLY WELLS ONLY: _ f 24d.For Water Wells producing over 100,000 GPID:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
ield(.Pin)_ 3 !.'Q: '63u l or test: f d j
pp p
04sinfzctiontglpe: 0% EMI � V-1l E.ntoum': O 0 Date Site Vi site8.­ /- "V
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e
Horth Carolina D n o nv+romnental Quality-Division of Water Resources. Revised 6-6-2018

OWNERS NAME:
ADDRESS.
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WELL CONSTRUCTION PERMIT
"gym Davie County Health Department - `
210 Hospital Street . CDP file!Number: 29Q43�
P.O. Sox 848
County:File Number:
.� �. Mocksville NC 27028
Date: .0.7./.0 9 2.0.2.0.
Drawing Type: Well Permit
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6
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