GW1-2021-07517_Well Construction - GW1_20210903

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WELL CONSTRUCTION RECORR MW-I) For Internal Use Only: - -
1.Well tractor Information: -
14.WATER ZONES
9ontraMarNatne FROM TO I DESCntMON
� 34//-A n FL 1a ft. S �Pm
NC Weil Contractor Certificadon N bee rX0 fL r r LD ft em
15.OUTER CASING for mrdfl�sed wells OR LINER a a6lc
FROM TO DIAhtET£R TFQCIa'FSS MATERIAL
0 7/ fL h G
mpany Name IF
/� 16.L4'NER CASING OR TUBING rind d
2.Well Construction Permit#: 3Q 3 ,A) E L R 70 FROM TO DIAWITA I THICKNESS MATERIAL
List all applicable nrll construction permits(i.e-UIC,Coun(r.Stare.Variance,etc.) O ft. O a ft IO c'
3.Well Use(check well use): It. iL In
Water Supply Weil 17.SCREEN
FROM TO DL4LMEM SLOTSITE THICKNESS I MATF.RIA
Agricultural E)Municipal/Public M R. in.
eothemtal(Heating/Cooling Supply) We idential Water Supply(single) ft. H. in.
industtial/Commercial Residential Water Supply(shared) Ili.GROUT
$rl tion FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O fL o2 O ft. Die d Ot)C e
Monitoring Recovery fL t D Z u- Otz s COI
Injection Well: W ft.
Aquifer Recharge [3Grounduater Remediation
19.SAND/GRAVEL PACK teable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft,
Experimental Technology OSubsidence Control R. tt
Geothermal(Closed Loop) []Tracer 20.DRILLING LOG attach addiflood sheets If
Geothermal Heatin Coolin Return) nOther ex lain under#21 Remarks) FROM TO DESCRIPTION color,hardneu,soWnx*n sire,etc
O OZ rr. i.
4.Date Well(s)Completed: !'�.ZS-�020 Well ID# /.O R'
Sa.Well Location:
Facility/OwnerNarm facility M#(ifapplicable) f. N
�:Z 0 u Yl t Q q ft. &
Physical Address.City,and ZIP k R' P
A)gmancc_ 9Lasgg/0q3 2LREMARKS proce
comfy Parcel Identification No.(PIN) Information
D
5b.Latitude and longitude In degreedminutes/seconds or decimal degrees:
(if well field,one fat/long is sufficient) 22.Certification:
l/-aS-ao 20
6.Ware)the weli(s0fe—rmanent or Temporary ignature of Certified well Contractor Date
B)'signing this form.I hereby certify that the'rmll(s)was(nrre)constructed in accordance
7.Is this a repair to an existing well: Wes or []No with 1 SA NCAC 02C.0100 or ISA A'CAC 02C.0200 li'ell Construction Standards and that a
If this is a repair,fill out known uell construction information and explain the nature o(the copy of this record has been pro tided to the kill airier.
repair under#21 remarks section or on the back a0his 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
construction,only 1 GW-1 is needed Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMiTTAL INSTRUCTIONS
9.Total well depth below land surface: 00 24a. For All Weil: Submit this form within 30 days of completion of well
Fin•multiple wells listall depths trdii jermf!example-3 tl 00'anndd 2ta^,109) construction to the following:
IA Static water level below top of casitr: J (ft) Division of Water Itesouna,Information Proeessieg Unit,
Ilxuter level is above casing.we"+" r 1617 Mail Service Center,Raleigh,NC 27699-1617 r
11.Borehole dfatneteir Y� (in.) 24b.For jaiectinn Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: A r i Q'l a r (/ construction to the following:
(Le.auger,rotary,cable,direct push.etc.) 1 e
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Ault Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24e.For Water-aunty&Infection Wells: in addition to sending the form to
the address(es)above, also submit one copy of-this fort within 30 days of
rib.Disinfection type: Amount, completion of well construction to the county health department of the county
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