GW1-2021-07476_Well Construction - GW1_20211116

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
L Well Contractor Information:
&d✓ A gen 5[aie_ 14.WATER ZONES
Well C ctorName FROM TO DESCRIPTION
It-
NC Well Contractor Certification Number
M OuaR CASING for multi-cased w& OR LINER da Geable
Dobv'S Well Sri ll;rtex FROM TO DIADMER 1HICKNESS MATIIty1y
Company Name 3-6 ft ioVY in' S0R-21 I PVe
�y 16.INNER CASING OR TDBING(geothermal dosed-laoul
2.Well Construction Permit#: i 7(ooZ 1 r7 FROM TO I DIAMErE.R MUCK NFSS NIATERUL
List all applicable well consimc ion permits lie.u1c Comity,State,Variance,etc) ft. a. in
3.Well Use(check well use): II. ft. in,
Water Supply Well: 17.SCREEN
FROM TO DLU11ElER SLOT SIZE THIC8INNFSS MATERIAL
❑Agricultural ❑M aMblic n, & in.
❑Geothermal(Heating/Cooling Supply) IaResidential Water Supply(single) M M im
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ' ❑Wells>100,000 GPD FROM TO MATEtuAL EMPLACEME NT AIMOD&AMOUNT
Non-Water Supply Well: 0 tICgo M Ben ! t O Ic
❑Monitoring OR-very ft. M
Injection Weil:
❑ tfer Recharge M R'
Agtr' barge ❑Groundwater Re;me:dia]Remarks)
❑Aquifer Storage and Recovery ❑Sal�ny gamma19.SAND/GRAVEL PACK da tieable
FROM TO MATERIAL EWL&CEMENTMErMOD
❑Aquifer Test ❑Stoffiwater DrainageM ft.
❑Experimental Technology ❑Subsidence ControlM ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRII,LING LOG attach additional sheets if nccnsa
❑Geothermal(Heating(Cooling Return) ❑Other(explain under# FROM TO DESCRIPTION(color.bardness,soahock qM Vain sbpe,etc)
n. n
4.Date Well(s)Completed: Well ID# .39 tt 825 6C 'Ie
5a.Well Location: R. My fl YeJ ice-
1 Yvonne Demme( Iz 31P0 n' 6ran �e-
Facility/OwnerName FaciI4ID#(ifapplicable) JUL ft
(J Deco For Rd ft ft
Physical Address,City,and Zip IL M
^s�e- 1&a215-a 1 21.Mb ARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification: ORM,�nn�l gRnP' r^Jplr r.
// 3-t8�D21
6.Is(are)the well(s): MI ermanent or ❑Temporary Sr Certified well Contractor Dare
By signing thisform.I hereby certify thatthe tvell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 8No 1 SA NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out!mown well construction information and explain the not=of the of this record has been provided to the well owner.
repair under t21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For GeoprobeIDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 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 INSTRUCTIONS
9.Total well depth below land surface: 3146 fr
For multiple wells list all depths tfdifferart(example-33L@200'and 2Qa 1005 ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 70 24a. For All Wells. Original form to Division of Water Resources (DWR),
if water level is above casing.use"�" ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter. L �y (ia.) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
pp Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: �i r f\4QfI/ 24c.For Water Sa
(.e auger,rotary,cable,direct push etc.) ppiy and Open-1 op Geothermal Return Welds Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells prodmftvver 100.000 GPD:Copy to DWR,CCPCUA
13a.Yield(91 m) Method of test: Permit gram,1611 MSC,Raleigh,NC 27699-1611
_1t1�
13b.Disinfection type: r/�r/ Amount _! 02
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Re%ised 6-6-2018