GW1-2021-03449_Well Construction - GW1_20210811

WELL CONSTRUCTION RECORD _
This form can be used for single or multiple wells
1.Well Contractor(Information,
FROM
WATER ZONES
� fltOM 7o DESCRIPTION
hell Contractor Naiue fe. ft.
! ✓. a
f-j h• fa.
NC'Well Contractor I IS.OUT CASING for wells OR LINER ifs k
i fRa,K TO DIAMETER TAUGUNI+E`S MATERIAL �!
! ! O fa,. L40 it. in;' cat 'V
Compaq Nam: ..16.INNER CASING OR tlreidnl closed
I + �1 0@ 1� FRO MTO DIAMETER THICK^( YlA RSAL
2.Well Construction Permit#:_Gel fI, ft, in. }
Lot ntf apph'uthle eel/eruirtracihilr perntur fi•e.C'ourin',Store,Irarrane..etc.1 ft. ft. in•
3.Well Use(cheek well use); 27 SCREEN
Water Supply Well: Atom To DLtdtfTER SLOTSIZE THICKNESS hSATfRtAL
OAgriculturai D1A3uaictpa}/Public
ft, fir. in.
0Cmathennal(Heating/Cooling Supply) Vl-idcnttal Water Supply(stngte) ft. ft. in.
�slndustriallCommercizi t7Residenttal Wale'r Supply(shared) I&GROUT To I MATERIAL 1 Eh1PLiC£MVZTMVHOD&Aatoc:�r
.^.Irritation ft a�} ft. 1 JS Y
Nou-NN'ster Supply Well:
ft. fc.
D'Acti onng DRecovery
Injection Well: ft. ft. 1
GAqutfer Recharge --Groundwater Rcmediation .19.SAND/GRAVEL PACK lif applicable)
CAquifer Storage and Recovery 0salinity Barrier FROM ft. fr.TO MATERIAL EXPIAC£MEy1}SETHOD
0Agtdfer'rest CStonnwattrDrainage ft ft
OEaperimental Technology Dsubsidence Controi 20.DRILLING LOG attach addidotal sheets ifnacsstory)
0Geothermai(Closed Loop) DTracer vaAM TO DESCRIP'I•ION calar,han3:sas,sat/cnckn a ralnsiu.etc.
CGeothermal(fieatin Cooling Return) GC#ther(explain under 421 Remarks) ft� ft-
�n fa ft.
4.Date Welt(s)Completed: �1 ft. !i.
'A.Well Location: fr. ft.
fr. fr.
mn I aeild).Qtu,ec ve Facility ID-(ifapplieable) ft. ft.
r f7t faed
C $
Pis zi Address.Cst),and Zip21.REMARKS \! ;Ot ..•+
nln 339
C'ounu Parcel ideruilication\a (PIN)
5b.Latitude and Longitude in degrees/minutes/secouds or decimal degrees: 22.Certification*
(tfvveil field,awe Mi.long ss sufftctent)
signatureofCcnified Well Contractor Datc V
6.Is(are)the x'eli(s): 6ermaaent or ClTetnporary
By.rfBiiw/,t this jan0,/brrrh}•errte#that r/rr srrllly sin,'(trrnry trur.Wruuatf ur tteenrduntr
kith 15A Nr'AC 0?t'.010rr nr ISA t W*02C Wilo J*d C irnetrretruut.Gtutdr+rtls and(hilt n
7.Is this a repair to an existing well: Oyes or 11N0 sr,ps'r)tftts rrtrrrd ltaa Aeru prrtvidrd to the well un'ner:
/1 then r.,et raptor.fdl nit%lwattn n e//nutvvuc'lturt w1brinaaan and atrphr/n the aarure tit the
re/wrr renJrr:r?l roararJrr srcvarti nr rni the back of rhi�•jnrrn. 23.Site diagram or additional well details:
(( You may use the back of this page to provide additional ttell Ono details or well
8.lumber of wells constructed: I construction details You may also attach additional pages if necessary
For nutlrrple rrrtrcirrn err nutr•trvk r xup/t/t a el/s 0.VL 1 27'+th.lhv cams C(rurrratdtUl,fYitJ ton e;
.uhnu+une J,rmr 24.Submittal Instructions:
9.Total well depth betmir land surface:_ �(ft.) 24a. For An Wells-, Submit this forni within 30 days of completion of%tell
Fur andrltle a elt.her a//depth.,it dilterent fe.viorph••3.^s&200'04d?et 11irr) construction to the following
r
10.Static water level below top of casing: D,,, (ft.) Division of Water Quality,'Information Processing Gait,
rt+rur.rterrir:uiurrcxt..,.,t,rx,e t - 1617 Mail Service Center,Raleigh,NC 27699.1617
11.Borehole diameter: tSJ (in.) 24b. For In ettion'%Veils: In addition to sending the form to the address in 2:a
above, also submit a copy of this form within 30 days of cumpiruon of%veil
12.Well construction method. LeliaY_ L/ construction to site following.
it a auger,rotary.cable.dirc.t push.ern.) I —
Biv'ision of'ltater Quality.Underground Injection t:onrra!Program,
13.FOR WATER SVPPLV WELLS ONLV: 1636 Mail Service Center,Raleigh,NC 27699-1636
t '►4ethad of test; 1 l t 24e.Far Water Suneily&Geathermitl VkSlls: In addition to seadmg the form a,
t3a.1'ield(gpm) ►r �j}}t� _ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 41 l o r me Amount: _ completion of well construction to the county health depanntent of the county
where constructed.
Form GU*-I Nonh Carolina,Department of Environment and.Natural Resources-Division of Water Quality Rev ised Jail 2013