GW1-2021-07904_Well Construction - GW1_20211102

WELL CONSTRUCTION RECORD(GW-1) _ For Intemal Use Only.
1.Well Contractor Information:
edr-n iJF+�4 14VYATER7ANES: s, '
FROM TO DEBCRIPIioNr
WellClooutraetarName �r\1 .� ft, t�0 g• ?0+
NC Well CormactorCertificationNumber n.?.�''�
., <15:AUTERG faimitHeas�tidiiel6DR`
t. ,, W e / 1 ,�,'� FttoM To DUMezBR btAraernr.
up/ r, t t� N t in.
CompanyNatre ;w O C '7 q r(j—,Z � ':16 Il RGi481N. .'OWTOBWG' MA78RI L
2.Well Construction Permit M Ui �7 1 G� FROM M D1eMe—K I rH1Cx M
List all applicable well construcnon permits(Le.WC,County.State,Variance,etc-) ft. R tO
3.Well Use(check well use): ft ft,
Water Well: 17.SCHEEN
Supply PROM I To MANMM sLOTsra TEMCIM s MATIOUAL
OAgticultund OMunicipaUPublic R f0 tc t- io y �Q D !
OGeothermal(Heating/Cooling Supply) 0111--i dential Water Supply(single) R ft. in.
OindustriaUCommercial OResidential Water Supply(shared) ILAMOUTY ifl »sue x L '
Olfriaittion OWells>100,000 GPD FROM I TO MATERIAL YJ U L ACEMBNT OD&AMOUNT
Non-Water Supply well: 0 IL (! I V e
OMonitoring ORecovery ft. ffi
Injection Well: & fL
OAquifer Recharge OGrotmdwater Remediation
OAquifer Storage and Recovery OSalinity,Barrier FROM I TO MAMMAL t�11Tr1 ACaM&�177 bIE1HOD
OAquifer Test OStormwater Drainage m M
OExperimental Technology OSubsidence Control ft• iL
OGeothetmal(Closed Loop) OTracer 1A:DRILLINGEO(i' iiddttlonl:i6ceb`if` :tlx:
OGeothermal eating/Conlin Return OGther(explain under#21 Remarks FROM To DFSCRIMON color,torch sottlroetc e L
4.Date Well(s)Completed:/Q"'(T J l well ID# ft' G/4 40
Sa.well Location: �-tl I SQ it 5.alv
FacilitylOwner Name ( Facility MO(if applicable) % ft
Cr % tL
Physical Address,City,and Zip ft. ft.
21vBBMARSS
County L� Pmoe)Identification No.(PM � G'G &Cofe6t e v/►d
Sb.Latitude and longitude In degreeshNnutes/seconds or decimal degrees:
(ifwell field,one Iatflong is sufficient) 2L Certification:
6.h(are)the well(s): Permanent or OTemporary Sipanuc of Certified well Conhmr Date
By signingthisfam,Ihereby cernfythat the wells)was(were)constructed in accordance wdrh
7.Is this a repair to an existing well: OYes or o 15A NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a copy
Ijthis is a repair,fill out IMOM well construction information and explain the nature ofthe of this record has been provided to the well owmer.
rryair under 021 remantr section or on the back ofthis form.
23.Ste diagram or additional well details:
8.For GeoprobeMPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional wall construction info
construction,only 1 GW 1 is needed Indicate TOTAL NUMBER of wells (add,See Over'in Remaxim Box).You may also attach additional pages if necessary.
drilled: ,t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below laud surface: /O� (R)
For tnulnple wrft list all depths(fdoer ent(example-3Q2/00'and 2@100� Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: / (fL) 24a. For All Wells: UriBnal form,to Division of Water Resources (DWR),
ljwnrer fever is above casing use"+^ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter. (m.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Pmgram,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Gr 24c.For Water Sup and en-Lon Geothermal Return Wells Copy to the
(Le conga,rotary,cable,dirxt posh,etc) county environments health department o the county ere
FOR WATER SUPPLY WELLS ONLY: jj 24d For Water Wells rode over 100 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) `" Method of test: Permit Pcogcam l 11 Raleigh; C 27 99-1611
13b.Nsinfecfion type: Amount: t'Yl
I
Form GW-1 North Carolina Department ofEwA onme ntal Quality-Division of Water Resources Revised 662018