GW1-2021-05936_Well Construction - GW1_20211115

NLL(:U1V.9tKUC;11(ll�l KM t,:Vlill(liW-i1 For internal Use Only:
I
1.Well Contractor Information:
(�rya d y----P-Qo I e, 14.WATER ZONES.
Well Contractor Nance FROM TO DESCRf rlim
aka. .
% ft.
NC Weil Contractor Certification Number Pa a n 1 II 15.OUTER CASING for rrtalti caned welts OR L1NER ! Bcabte
�° -- -- -- - --ram
. . i u Jk_: fI. ..®D -- -="to _ W.„y.
G
CompattyName 16.INNF.RCA G:ORTU$IN eotherrrtal.Aoaed•tao
2.Weil Construction Permit#• FROM I To DIAoETER TFnCKNUs MATERIAL
List all applicable imil construction permits(i.e.UIC,County,State.Variance, ft+ ft• Ia
v,
3.Well Use(check well use): ft• 1n.
Water Supply Well: 17.SCREEN
FROM I TO I DIAMETER SLOT Sim THICKNESS MATERIAL
Agricultural uaicipal/Pablic ft, n is
wvuu6--y"St LyJ w%- , m—,raw%ouppq louutgw) ft. IL
In..
lr dustrial/Commtucial 1311osidentia]Water Supply(shared) It.GROUT .
lid 'on FROM To MATERIAL EMPLACEMFdV'fM1?MOD&AMOUNT
Non-Water Supply Well: 0 ft. o IL Q�► Q i�
t
Monito' Recovery ft ft,
njectlon ell:
Aquifer Recharge E)Groundwater Remediation ft t9.SANINGRAYEL R ft. itcable
Aquifer Storage and Recovery DSalinity Barrier FRoar TO MATERIAL EMPLACEMENT METROD
i 4u,ic%iwi L jaiunnwamr wramage +« « r
Experimental Technology Subsidence Control
Gcothennal(Closed Loop) Tracer 2a DRILLING LOG aUaeh addMeW sheets R a
Geothermal(Heating/Cooling Conli Return Other(explain under#21 Remarks FROM To n eotor aarda .oniraelc n etc.)
4.Date Well(s)Completed: �[ - �1 -a Weil ID# S R• R•
roc
Sa.Well Location-
-. e,I Cf. e ft. ft.
Facility/Owner Name Facility!D#(ifapplicabie) ft. fL —
T o h w �' 1 1 ft. fL -
Physical Address.City,and Zip �� ft ft. DWRI A!
_\U k ke., 21.WMAM I U 6,'M
­_VCZJUINV W41 r
Cauner Parcel ideatifteationNo.(PIN)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well$elrl one W/Irma in Kufficienkl
N W Ylot
6.Is(are)the well(s)GtPermanent_ or ElTemporary SiPQ0WWA Date
By signing this form.I h }cerllfy that the sells)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or �No with ISA NCAC 02C.0 or ISA NCAC 02C.0200 Well Construction Standanh and that a
Ifthiv is a rgWr,fdl our Irons+well cnavtrucdon information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back ofthta form.
23.Site diagram or additional well details: .
8.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
constiuction,only I UW-1 is node IntUcate TU'1'AL NUMBER Of wells CVU000UiiVU UCV4 b. i UU u%ay aiiu aiiuun auuiuunai pages iiuccessary.
filed' r/ SUBMIUAL INSTRUCTIONS
9.Total well depth below land surface: b0 (R•) 24a. for All Wells: Submit this form within 30 days of completion of well
For multiple wells list all dap&J'dffierent(example-3@-100'midr2@10U) construction to the following: !
10.Static water level below top of casing: dt0 (ft.). Division of Water Resources,Information Processing Unit,
(fanter level is above casing,use'+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: (in.)
+ 24b.For IaiecgQg Wells: In addition to sending the form to the address in 24a
12.Well construction method: �'r 0 !A I-! e,»i b r:: ae c::Y;
(le.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm) 3 _ Method of test: 10 V1 24c.For Water Sunny&Injection 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:4 Amount: �b completion of well construction to the comity health department of the county
where constructed.
Form GW-1 North Carolina Department ofEaviroomental Quality-Division of Water Resaurr ea Revised 242-2016