GW1-2021-04224_Well Construction - GW1_20210415

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20.DFIT-41,MG additional SL-eeis if necessary)
oGeovierrrial(Closed Loop) oTracer FROM TO DESCRY TICH(color,hirdnas,saiilrockt;pc.gml,
oGeothermal(Heating/Cooling Return) 00dier(explain under#21 Remarks) 0 /J, Ill. C/It
,A.Date 1711,lell(S)Completed: 3-0S-,2 I— Well 11D#-AAQL—T'71)— 1Y IS -5c,4
Sa.Well Location: Phone
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Facility/Oivner;Aame Facility IDN(if applicable)
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Physical Address,City,and Zip'
21.RERM2UMS
Counq Parcel Identification No.(PIN)
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees.
(ifwell field,one lattlong is sufficient) ­7-1,j 22.Certification:
6.Is(ire)the well(s):4rnanent or OTemporary Signature of Certified Well Contractor Date
BySigl1h7g this fomi,I hereby certy),that the well(s)was(were)construcledin accordance with
7.Is this a repair to an existing well: oYes or V41 15A AICAC 02C.0100 a)-15A ArCAC 02C.0200 rile//Co),stiiction Slotidards and that a copy
If this is a repair,fill out Nown u,ell co)lsllllclio)7 j),fol-Ination and explain the nalure of file of this record has been provided to the-well oisner.
repair under#21 remarks section or all the back ofthisforn). 23.Site diagram or additional well 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 construction info
construction,only I G"AF-1 needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
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drilled:_ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 301 ' (ft) Submit this GW-1 within 30 days of well completion per the following:
Fo)-1111,11iple ji,ells list all depths tfdifferent(Pxwnple-3@200'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 30 Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifil,ale).level is above casing,use"+" I
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B'toff: 24b.For Injection Wells-Copy Ito 1DW`k,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
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12.Well construction method: AIR ROTARY on For Water Supply and Open-Loop Geothermal Return Wells:
EN as:Copy to the
(i.e.auger,rotary,cable,direct p 'etc.)' county environmental health department of the county where in
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DVvrR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27 9-1611
13a.Yield Win) Method of test: azeif i
136.Disinfection type: 70%H T H Amount: 16 Oz DATE SITE VISITED:
VISITED BY:
Revised 6-6-2018
Form GWA North Carolina Department of Environmental Quality-Division of Water Resources A W.q\ i .