GW1-2021-07585_Well Construction - GW1_20210903

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WELL CONSTRUCTXON RECORD(9W-1) For Intemal Use Only: =
1.W C ctor Information.
14.WATER ZONES
2el FROM TO D ON
ell Contmctor Name nn P
N�W It Contractor m r 1 ve IL ?a f- a fl PM
15.OUTER CASING or mttttl eased wells OR LINER cable
/) FROM TO DIAMETER 7AICfU�SS MATERIAL
Corn ry Name
16.INNER CASING OR TUBWG d
2.Well Construction Permit Jr.15 y,q2,4A PA FROM To DIAMIrmit I TFUCKNEss I MATERIAL
List all applicable well construction permits#et IC Cormfy State Var(ance,etc) ft. % In.
3.Weil Use(check wen use): It. %
17.SCREEN
Water Supply Well: -FROM TO DIAMETER .SWT SUZ I .TMCUNM I MATERIAL
Agricultural [3Municipal/Public 2 to 11L
Geothermal(Heating/Cooling Supply) Wmidential Water Supply(single) R, It. in.
Industrial/Cotnmencial EIResidential Water Supply(shared) le:GROUT-,
:[irrigation FROM TO MATERIAL E0tFc wCEMMMW M ETFion&AMOUNT
Non-Water Supply Well: M &
Monitoring Recovery IL tL
Injection Well: R fw
Aquifer Recharge QGroundwater Remediation
19.SAND/GRAVELPACK i e ;
Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL EMPLAClEMENTMETHOD
Aquifer Test ElStormwater Drainage tL r,
Experimental Technology [Subsidence Control ft. it
Geothermal(Closed Loop) 0T-- 20.DRILLING I.OG atmch addiftard sheets if
F$OM Geothermal(Hearin Doling Return Other lain under#21 Remarks TO DESCRIMON color, mn/ro& etc.)� � Y_O � `
4.Date Well(s)Completed: �� Well ID# ZO f iz r.o-
5a.Well Location: P 0 C
n' 4 cl
Facility/Owner Natce Facility M#(ifapplicable) (L it.
T5N WlkincVlel Lki ft ft.
Physical Address,City,and Zip R &
416m to t^a fr?Y 2 640 O zL REMARxs
a
County Parcel Identification No.(PIN) $$1f1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: tpn PfACB.
(if well field,one Mang is sufficient) 22.Cerdflarallan
�W�
� �y �qN W (/i ` Y —11 �Go
6.Is(are)the weH(s) ermanent or [Temporary ofCenified Well Contractor Dare
Zsig7- g this form,i hereby certify that the m11(s)nm(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or V00o with 1 SA NCAC 02C.0100 or 1SA NCAC 02C.0100 Well Construction Standards and that a
Ifthis is a repair,fro out known Weil construction iglarmation and explain the nature of the ropy of this record has been provided w the my owner.
repair under 421 remarks section 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 site details or well
construction,only I GW-I 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: ZD (150 24a.!Ar,All Xel Submit this fort within 30 days of completion of well
For muWe wri/s list all depths ffdiffervtn(example-3(a)200�'and 2@1007 construction to the following:
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10.Static water level below top of easing: V (ft.) Division of Water Resources;iafarmation Processing Unit,
If mter level is above casing use'+' 1617 Mail Service Center,Raleigh,NC 27699-1617
1L Borehole diameter. A) (in.) 24b.For Infection Weil%: In addition to sending the form to the address in 24a
tf above,also submit one copy of this form within 30 days of completion of well
12.Well construction method. 266 Kd construction to the following:
(i.e.ange,rotary,cable.direct push etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27690-1636
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13a.Yield(gpm) Method of test: 24e.For Water Supply&infection 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�cowtty health department of the county
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