GW1-2021-03368_Well Construction - GW1_20210603

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: r
1.Well Contractor InformMm
14,:WAr1'ERZAN$3.
Well Contractor Name If
FROM ft. TO DESCRIPTION
ft. f t.
. rt.
NC Well?ntractor Certification Number 1s.0 TER.CASINO f6rmulti.00itd•we is 0R`LINER.its llik le L40
rFROM TO DIAMETERR-t THICKNESS MAATERIAL
CompanyyNaom(e �f�1�.��lIIJJJ —/ (C/� ft. ' ft.
�j t 12- _°. .'9'
V v / D D G D 16.'INNER:CASINC.OR T[1BING: cofhermal'lased=loa
2.Well Construction Permit#: FROM1 To DIAMETER THICKNESS I MATERIAL
List all applicable evil consh action perwrhs(i.e.UIC,Countq State,Parlance,etc.) ft. tt. In.
3.Well Use(check welt use): ft. ft. In.
Water Supply Well: 17,SCREEN'•::
ppy FROM I TO DIAMETER S LOT SIZE THICKNESS MATERIAL
Agricultural [3Municipat(Pubiic ft. ft. In.
Geothermal(Heating/Cooling Supply) ffResidential Water Supply(single) n, ft. la.
Industrial/Commercial ORcsidential Water Supply(shared) 18,GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft. aw ft. b' one l 1 b 5
monitoring Recovery ft. Pt.
Injection Well:
ft. It.
Aquifer Recharge QGroundwater Remediation
-19:'SAND/GILIYEL PACK IPa bIicablc
Aquifer Storage and Recovery OSalinityBaffier FROM TO TATERIAL .EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) DTraccr 2.0:DRILLINGLOG.aHacb addlHoital sliecti if pecesse'' .
Geothermal(Heating/Cooling Return) r3Other(explain under#21 Remarks) FROM To ft. DESCRIPTION color,hardness soWrock type, rain size eta.
ft.
4.Date Well(s)Completed: Well ID# A
So.Well Location: J Pt' 2145 ft' Gf b t° r6 L
Moas Vo d ex
Facility/Owner Name t Facility ID#(if applicable)
101-7 ah krc,' -. P44 n.
Physirt
ddr s,City,and Zi i Q
fj V. "B Z1.REMARKS ' .
County C. C Parcel Identification No.(PIN) on s•
ing Unit
D���is Section5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
40 toa1 N W
6.Is(are)the weII(s) Permanent or, Temporary Signature of Certified Well Contractor Date
By signing flits form,1 hereby cerftfy that the well(s)was(were)consiructed In accordance
7.Is this a repair to an existing well: [3Yes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consa ruction Standards and that a
If INS is a repair;fill oil/known well eonsh•net/on hrfavnailo and eaplaln the nalin•e of the copy of this record has been prodded to the cell owner.
repalr under 1121 r marks section or on the back of this forin.
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 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: ZL SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
!a multiple wells list all depths Ifdoerent(example- and 2@100) construction to the following:
10.Static water level below top of casing: 5_5 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"4- 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: ���t�i1-� construction to the following:
(i:e,auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service''Ccntor,Ralclgh,NC 27699-1G3G
13s.Yield(gpm) Method of test: a 24c.For Water Supply&Inieiction Wells: In addition to sending the form to
c I the address(es) above, also submit one;copy of this form within 30 days of
13b.Disinfection type: d n n Amount: f completion of well construction' to the county health department of the county
where constructed,
I
i
Form dW-i North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016