GW1-2021-05933_Well Construction - GW1_20211115

WELL CONSTRUCTION RECORD Lq W-11 For Internal Use Only:
L3Vel(l/-Contractor Information:
USX _ - lq.. .t. F.
Well CoMrector Neilfe FROM To D$SCKnMN
NC Well Contractor Certification Number
"'/•Q • 7.Jl1?I Z Q!I ` ��M 1 t FROM WTO DIAMETER v THICIUMS NIATENIAL
T—� J� %
2�Construction Permit#: 67 D 5 g 315 0 1 FROM TO DLtMETER mcwaa a~MATERMAL
List all appAwble well construction permits(l.e.U1C,County.State,Varwee,etc.) ft. t?. to.
3.Well Use(check well use): ft. ft. In•
[A�eqcouffi'111
npply well: DW RTER SLOTUM CKNM MATERIAL
ltural Municipai/Publicrmal(Hesting/Cooling Supply) Residential Water Supply(single) h• f, to.
ial/Commercial (3Residential Water Supply(shared)kdotion FROM T8 EMM ACEMBT1TMETHOD&AMOUNTater Supply Well: ft. ft.oring Reco tt. tt.e :r Recharge E3Ghoundwater Remediation `� `�r Storage and Recovery �Satinity Barrier FRo1K To 4 MATt3AfAL CBhiRh'r METROD
Aquifer Test 08tormwater Drainage IL ft.
Experimental Technology 13Subsidcnce Comrol ft. ft.
Geothermal(Closed Loop) 13Tracer 4 , , .' _ ... 1t, ..�� :. ,.='; - •
Geothermal eat[ Doll Return) Other(explain under#21 Remarks FRtnN TO aESCRit�'140N eolor bare soithaa& c *a
O tt. oft. SD t r
4.Date Weli(s)Completed: r G a�Well lID# a ft• 70fQ 4
Ss.Well Location: 70 O' Cad R' /-4ht e- ft G :CIF
Lj
F-114/0nmer Name I n/ Facility if applicable) ft. ft, 2l
Physical Address,City,and Zip fL R.
W ;w; 1 l PROCES
A i
Couaty Parcel Identification No.(PIN)
5b.Latitude and longitude in degreWtulautes/seconds or decimal degrees:
N W
6.h(are)the wells) Permanent or Temporary Signature ofcartiflefWall Pntraclor Date
By signing this form,I hereby certify that the xrll(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yea or No with ISA NCAC 02C.0100 or ISA NCAC 02C.0100 Well Construction Standards and that a
If this Is a repair,Jiif out known well construction information and explain the nature of the copy gfthts record has been provided to the well owner.
repair under 421 re narb section or on the back of this form.
23.site diagram or additional well details:
g_F e t r(7--n-IerAr-fDPT nr tIn--e..4 7.:rn::t~sath 1 WP.M-e hav;IIa+:,nM„n You may use the back of this page to provide additional well site details of well
construction,only I GW-1 is needal. Indicate TOTAL NUMB of wells construction details. You may also attach additional pages if necessary.
wed' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: O (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths f/'difflbvn1(sample-3Q200'and 2@1001 construction to the following: i
10.Stadc water level below top of casing: R O (W Division of Water Resources,Information Processing Unit,
(/'water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:_„-_(in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
�e uuuvc,aesu subunit uuc cupy vi rue iutm wiiniu 3v days ui cumpieuun of well
12.Well votary,cable,
, method: q l P r,014 / construction to the following:
(i.e.anger.rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: L 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3. Method of test:, f�)ow 24c.For Water Supply At Intecittm Wells: In addition to sending the form to
the address(es) above, also submit 'one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where Constructed.
Form GW-1 North Carolina Depattruent of Fa►viroamentel Quality-Division of Water Resources Revised 2-22-2016