GW1-2021-07474_Well Construction - GW1_20211116

U WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
1.nnWell Contractor Information:
Cit y 1/en S a� 14.WATER ZONES
Well Can ctorName FROM TO DESCRIPTION
it ft. 1(\
ll395-A 3Ll f
NC Well Contractor certification Number
3�to � t >ti
jj�� L is OUTER CASING for multirased weds OR LINER ata 'mble
�I o V 6 5 —Well �r l(' t Ytd FROM TO DIAMETER 1ffiC[NM MATERML
Company ame O fL 104 ft.
1s l/y ID' I $OR 21 QVC
• n��,� 16.INNER CASING OR TUBING thermal doseddoo
2.Well Construction Permit#. O( 5 FROM I TO DUMETER I THICKNIESS AUTER„r_
List all applicable well construction permits(Le.VIC,County,Slate.Yarfmrce,eta) 1L It. in
3.Well Use(check well use): It. IfL to
Water Supply Well: 17.SCREEN
FROM To BUMETER SLOT SIZE THICRNESS MA�IAL
❑Agricultural ❑MunicipaVPublic n. I IL hL
❑Geothermal(Heating/Cooling Supply) lRitesidential Water Supply(single) IL in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) I&GROUT
01irigation' ❑Wells>100,000 GPD FROM TO MATERiAI. EIHPLACEAI) r MEIHOD&AMOUNT
Non-Water Supply Well: tt -25 tL SeA{o ikG f
❑Monitoring ❑Recovery M ft. e
Injection Well:
it❑Aquifer Recharge ❑Groundwater Remediation tL
PACK
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL rf alivableFROM TO n1A'e'Fnrsr. EAD IACEl1TENNT METHOD
❑Aquifer Test ❑Stormwater Drainage n fL
❑Experimental Technology ❑Subsidence Control [t. fL
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLiNG LOG attach additional sheets if neceIssa
❑Geotheffial g/ hug ) ( FROM TO DESCRIPTION(color,hardness,-W ock saq eta)
(FIeatin Coo' Return) ❑Other lain under#21 Remarks) 11-
4.Date Well(s)Completed: 3- S-521 Well lam# 92 ft- lal lal "L
So.Well Location:
�Sattbat'a D -Mef I= n 3y0 rt'
Facility/Owner Name Facility W#(dapplicable) 40 B' 341 ft. Crevice
W -0—OaQ GC44 3N I L qpp it. Gfan;lrle
Physical Address,City,and Zip IL It. A'
O I
�4SIRF P�a�S —v]t� 2LREMAJW
County Parcel Identification No.(PIN) C m
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N W
6.Is(are)the wen(s): lhermanent or ❑Temporary Signature o(EYtified Well Contractor Date
By Signing thisform.l hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 8No I5A NCAC 02C.0100 or I SA NCAC 02C.0200(Pell Construction Standards and that a copy
Ifthts is a repair,fill out!mown well construction information and esploin the nature ofthe of this record has been provided to the well owner-
repair under=21 remarks sechan or on the back ofthis 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 construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRIICITONS
9.Total well depth below land surface: fL)
For multiple wells list all depths ifdiprent(rumple-3@200'and 2@100) ( Submit this GW-1 within 30 days of wen completion per the following:
10.Static water level below top of casing: [e0 24a. For An Wells: Original form to Division of Water Resources (DWR),
If water level is obory casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter. jp t�N (in.) 24b.For Injection Wens:Copy to DWR,Underground Injection Control(IUC)
A Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: �t �ar V 24c For Water Supply and Open Loop Geothermal Return Wells Co to the
(.e.auger,rotary,cable,direct push,etc.) 2 environmental health Copy
department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells rode ' lover 100 000 GPD:Co to D
13a.Yield(gpm) 5 Method of test: A t r Pemut Program,1611 MSC, eigh,NC 27699-1611 Copy 'CCPCUA
13b.Disinfection type: Y Amount:J%5 07— V
Form GW-1 North Carolina Department ofEacvonmentai Quality-Division of Water Resources Revised 64-2018
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