GW1-2021-05465_Well Construction - GW1_20210615

: :..'J7 cif_FROM TO
::
Atractor Name "
a Asa A 0 r�5V\ ft. ft.
INKIN
Contactor Certification Number y ��\ 15.OUTER CASIPTG(for multi-cased wells OR LINER(if a p6cable V
WELL COMPANY,INC. � FROM TO DIPS STCR TlisCra i TCRL L /
� ft. ft. 1 in. ` 1T
an
` p y Name 'C�``�'Q�v'•��'� 1G.INNER.CASING OR T[JBllVG(geothermal closed-loo
2.Well Construction Permit#: FROM TO DLANIETFR THICIMSs MATrRIAL
bf all;applicab/e well construction permits(xe.WC,County,State,Variance,etc.) 41 f' Lt3 ft' &Pq 1D' S 0Q71 P vC
3.Weil Use(check well use)! ft. ft. in.
17.SCP-FE i
91r8tCE'SoPPIyFSrell: rylord TO DVIVIETLR SLOTSIZE TOIC141ESC H Ainni_L
Agricultural ❑MunicipaUPublic ft. ft. in•
Geo4lzermal(Neadng/Cooling Supply) ❑Residential Water Supply(single) it. ft. in.
D7ndustrial/Conunercial ❑Residential Water Supply(shared) i:j,CpOU-
®Irri `tion ❑Wells>100,000 GPD MON To MATERIAL EMLr'LACEr.0NT P.IETHOD li A-HOUNT.
Non Water Supply Well: O it. S ft. Nok ft v ('oUMA S S
Olvlonitoring ❑ oovery s f+� ,O ft. 04at&M& P t{ tout»
Injection Well: ft ft. 1
uifer a Rechar ❑Groundwater Remediation
g 19.SASID/G-RA» L PACK(f applicable)
l7Atpifer Storage and Recovery ❑Salinity Barrier RON TO irr<�TERrAt EP.IFLACErIEP4T&IME117 OD
uifer Test ❑Stormwater Drainage f ft
t7Experimental Technology ❑Subsidence Control f'
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) Rona To DESCRIPTION(color,hardness,soiurocic n sae etc)-
Q ft. 4 t ft.
4.Date Well(s)Completed: S �� Well ID# i4o *5.72 35 ft' god ft G ron r 4r
5s.W.ell Location:
Phone # (70gt -ITS -S'bbl ft. ft
Atea.. Ipc'oSt-
Owner Name ! nn Facility ID#(if applicable)
cal Address,City,and Zip ft ft
3
21.REMARKS FraL c!
sty Parcel Identification No.(PEN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
well field,one lat/long is sufficient) 22.Certification:
N W W006- s �$
6.Is(are)the well(s): ❑Permanent or ❑Temporary Sigma of ed Well Contactor Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordmice with
Is this a repair to an existing well ❑Yes or t9N0 15A NCAC 02C.0100 or 15A NCAC 02C 0200 Well Construction Standards and that a copy
I this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair eider#21 remarks section or an the back of this form. 23.Site diagram or additional well details:
8.For You may use the back of this page to provide additional well construction info
;GeoprobeJDPT or Closed-Loop Geothermal Wells having the same
(add'See Over in Remarks Box).You may also attach additional pages if necessary.
ction,only 1 GW-1 is needed. Indicate TOTAL NUMBER.of wells
ed 1 24.SUBMITTAL INSTRUCTIONS
9 Total well depth below land surface: (ft) Submit this GW-1 within 30 days of well completion per the following:
Formultiple wells list all depths if different(example-3(a}200'and 2(a}I00)
24a. For All Wells: Original form' to Division of Water Resources (DWR),
10.Static water level below top of casing: -o (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwaterlevel is above casing,use
1 Bit Off: 1.,M3 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: & (in) Program,1636 MSC,Raleigh,NC 27699-1636
Z.Well construction.method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie.Huger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
i
OR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over,100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 1 Method of test:
70/o
o HTH OZ
4 DATE SITE VISITED:
13b.Disinfection type: Amount:
VISITED BY: W e r &A
r
FatmGW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018