GW1-2021-04158_Well Construction - GW1_20210827

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1.Well Contractor Informatifo`n: 1 l
Jul -/1 wy 1 C6W / 44.:WATERMNFS:.:; ,'m:..-,::i :,:'>as;':','•i v,,.,:;F_ r.:=;tor:.: .:•:..
WellContmctorName FROM 6 TO_ ..__ DFSCRIF171M/�
NC Well Contractor Cedification Number I5MUTER:CASING foeinnlfi�easid"welt+ OR'LiNER fun"'licuibie
GC �� Z��S y G t FROM TO DIAb=ER THICKNESS MATERIAL
tL- ft. l/ ft. in.
Company Name
x1
yy� ,.....,
�U �� '` 6.'IIMMICASINGOR.TUBING: eotlfifi l"elmedacu
2.Well Construction Permit#: r FROM TO DIAMEM : TMOOtFSS MATERML
test aU appricable eve►I construction permits(Le.WC County.Stara Parlance,eta) ft. ft. to.
3.Well Use(checkwell use): ft. IFL
Water Supply Well: 17.SGREEN4;s;:",':?r %'"i7:slier.' 1:;ci<;ii'.s`:;.i.' ii?>., ?;=`o• :%u'' . 'NtiS,.7 :? =
FROM ITO I DIAMIETER I SLOTSIZE TMCMESS ' MATERUL
..Agricultural [3MumcipaVPubl1c 0 fc ft: is
... Geothermal Oicating/Cooling Supply) Sidential Water Supply(singleft)
Industrial/Commercial r3Reside►tial Water Supply(slared iG
hL
)
.Y18iGROiP1'rt'•.�i: '.e...,.�:� '':is;?� .:? E�' :.,:i.Tiii::isr`:' 'i:��°•'ii}';;e. •:i
.—hrigation FROM TO ... MATERIAL EMPLACEMfEMPMETHOD&AMOUM
Non-Water Supply Well: O R N> R p pj Wt bi! pl,
95
Monitoring . Recovery fG ft.
Injection Well:
AquiferRecharge 0Groundwateritemediation ft R
:19:SAND/GRAVEL•PACK a'6611E01e}:'.S ;:iiic;:;lE;;.::S.'.''FS ?;; ;;ri:';•.,t,r.,s<e•
t-tAqui Stomp and Recovery OSalinity Barrier FROM TO MATERIAL I EMPLACEMENT 11MMOD'
AquiferTest 13StormwaterDrainage R IL
Experimental Technology OSubsidence Control i< fa
Geothermal(Closed Loop) OTrdcer .DRMLING LOG attaiihiid H8e`rdbbebts•ifiii+eessa'"
Geothermal(Heating/Cooling Retum) Other(explain under#21 Remarks) FROM To DFSCR@iION(color t+ordaess.soturoek eta
O f` a f` J✓ �Ill.564y Ovoilou CFO_
4.DateWell(s)Completed: Z welim# CG ft. f)G ft. f-•o '
k.
5a.Well Location: 116 f`• ft'
Facility/OwnerName - Facility IDS(ifapplicable) ft. &
PhyisicalllAddn ss,City,and Zip A. ft.
_//LI��L t iT.ItREdfARI{Sv}i �;�.yi»•o-%c�:i:+�r>, �`r'cy::':a7�rr7�:,ti:
County PameII&ntMcationNo.(PIN) y,1,.::pCoGC �..1.
V'J����:•
Sb.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(ffwell field,one lat/long is sufficient) 22.Certification:
S3y 'ss172A I `S, 3y, Syoel r zSZ
6.b(are)the well(s) Permanent or OTemporary -3fCatifillevdi Con Date
By signing this fount,I hereby care that the weit(s)was(were)eonstrurcted in accordance
7 Is this a repair to an existing well: []Yes or MeNo Irlih 15A KCAC 02C.0100 or ISANGIC 02C.0100 Wdl Construction Standards and that a
Iffthts is a repair,fr9 out/mown well construction information and uaphrin the nature ofthe copyofthis record has beenprovided to lhe;sreff oamer.
repairunder#21 remarlasection or on the backoffUsform.
23.Site diagram or additionalwell details:
S.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 OW-1 is needed. Indicate TOTALNUMBER of wells construction details. You may also attach additional pages if necessary.
drillod: SUBMITTAL INSTRUCPIONS
9.Total well depth below land surface: li 80, 24a.For All Wells: Submit this form within 30 days of completion of well
Farmub/p/e treUslLrt a!l depthslfdtfferent(example-3®100'a�n+d?aQ100� construction to the following:
10.Static water level below top of casing: .7 (ft) Division of Water Resout rest Information Processing Unit,
41mrierlevd 6 above casing.use"+" 1617 Mall Service Center,Raleigh,NC 276991617
11.Borehole diameter.. (in) 24b.For Infection Wells: In addition to sending the form to the address in 24a
k/► i-� above,also submit one copy of this Ifoim within 30 days of completion,of well
12.Well construction method: a C2 fQ r
(Le.auger,rota cable,direct push,etc-) construction to the fllowing:
ry,
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 276994636
13a.Yield(gpm) Method of test �!r 'L 24c.For Water Supply&Infection Wells: In addition to sending the form to
f, the address(es) above, also submit foee copy of this form within 30 days of
13b.Disinfection type: ( Amount d 2 completion of well construction to the county health department of the county
whore constructed.
Form GW-1 North Carolina DepattmentofEnvironmeatal Quality-Division of Wateritesourees Revised 2-22 2016
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