GW1-2021-03410_Well Construction - GW1_20210607

WELLCONSTRUMON RECORD For internal Use Only:
L Well C ntrsaar Urrormelton:
Daniel C.Veltfl 1
WellC.o�ctorNaw enon to DESCUMON `
NCWC 4368-A � .` ;t �C3 ���`tia Unit 62 & Vdb.Od
l�WelDCo�saorCictifiattoaNt®her �S$ i,+ R Sec"OG
Maupin Well Drilling LLC FROM To DLAMIC"M I9tf[C1OV655 1wAVERr v
Company Na t "� 2 I
Nam sdn40 pye
a7J`t2"!'t
+�5C,� A�fw ..;lfi.�rllOWSCA.iSINGiQR.Tf7$.ING`
2 Well Construction Permit#: FROM TO DIAMETER TRICIOn33 I MATEMAL
list al/appp=bk well consbucwn permiar fee&7C,Co m! &u,S Puri-XA ets,) n, % is
3.Well Use(check weft an): rt It. `
Water SW*wdi 17:SCREEN ''_
FROM I TO J DIAMETER 67.OTSIIE TWCKNESS,.}. MATBRUL
Agncohmal 13MunicipallPubfic ft. &2 IL 2 fa. 4mo sFluc p,y
Crenthuxinal(Heating/Cooling supply) BResidential Water Supply(single) ia.
Residential Water Supply(Shared) �B Gk0lD1
FROM TO_--� ;MA3ERUL EMPI.AULMFNTMSIHOD&AMOtW
Non-Water Sop*Wdi: f R. SS ft. halmha GmAY
storing -_ Recovery fL R.
Injection Well:
Reritulge 13Gtoundwater Remediation fL fL
fen Recovery �19 SAND/GRAVE4 ACIC
S d
turap and very []Salinity Barrier FROM TO MATERiAi. IIHPIACY1tfEDii METHOD
-
AquiferTest 13StormwaterDrainage 56 fL 62 fL fA tt r
Ell Technology Subsidence Control fL M
-GeMih�mal(Closed LOW) 0T__ :ZO`I)Rff.MGLOG sitich;aAdltfaniittiheetsfl
themral }in Rettnn} _Other{ ISIn nttder fl2l Remarks) FROM To DFSCR1Pi2¢N tutor aodihoe!
t fL 4 R. gray day
4.Date Wdt(s)Complaed:21 trt3y21 Wen En 4 ft, to n yallowsa�
Sa.Well Location. is fL 24 fL Shell and Clayr0ced
Tyler Reed 24 fL 28 fL luny day
Facilily/OwoerName Facility W#(if applicable) 29 fL x iL samlandsholmaed
515 Middle Gibbs{Gibbs woods 27950 34 f. 55' fL clay
Physical Address,City,and..Tap 55 fL 62 i6 samosa yebrg�sy tmna
CuRitudt 002900000560000 xf��1eEMss: ._
Comity Parcel IdOet ficalion No.OPIN)
5b.Latitude and longitude in degreeshninatestseennds or decimal degrees:
(ifweu field,one bUYmg is sufficient)
36-53414 N -76.09464 w
22 May 21
6.is(are)Me weil(s)OPermaneat or OTemporary Signawre ofCcnifiod well Dade
8v$igning this farm,I hereby C-01v that the we(s)mom(were')eonsfrV W m accordance
7.Is ibis a repair to an existing well: QYes or @No veil 15A NCAC 02C.0100 or ISd NCAC 02C.0200 Well Construction Standards and that a
O'dris is a repair,fdI aw brown well conshuetion utformatfon and eViam the nature of the copy of thu record has been provided to the%W1 ouner
repair order#21 remark swavo or or the bask ofdw form.
23.Site diagram or additional well details:
B.For GeoprobelDPT 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:
SUTBMDITAL INSTRUCTIONS
Farmalhptew,dhFnaa9depthsrfdilJermt
9.Total well depth below land goriaOil— a �+ (fu 2AL For All Wells Submit this farm within 30 days of completion of well
fesa+tep►e-3Ca).?00'+md1�t�'}10,Sufic water Neva below tap of casing 5' construction to the following:jwata lewd is aboreatshr�use (fL) Division of Water Rcsourcea,Informahlon Priming Unit,
"+^
„ 1617 Mail Service Cent,Raleigh,NC 27699-1617
iL Boreholedrameter Z (in.) 24h,For Iniection Was: in addition to sending the form to the address in 24a
12.Wed construction medm&. Mudrotary above,also submit one copy of this form within 30 days of completion of Well
(u eager:rotary,able,d'aest push,etm) construction to the following
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mai!Service Center,Raleigh,NC 2709-1636
13a.Yfdd(gpm)20 Methad of test:pacer Pump 24c.For Water Scanty le Infection Wells: In addition to sending the four to
13b.DianfetfioH Hypodttde 302 the address(cs)above,also submit one copy jof this form within 30 days of
tyP Amount: completion of well construction to the county bealth department of the county
where constructed.
Fonm GW-1 North Carolina Department of J!"Aranmental vitality-Division of Water Resources Revised 2-22 2036
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