GW1-2021-08149_Well Construction - GW1_20211109

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1,well Contractor Information:
14.WATER ZONES
Well ContractorName T FROM To DESCRiMON
9 D - ft. 5"MO-401
NC well Cmot/motor Cer"Cation Number 13.oDTSIt ' r IDttln=cased we usable
L — '• FROM I TO D1ANffiT8R FTWCKNM tItATERIAL
in.
iila"
Company Name icouall ORTO M thernmldond400
Z.Well Conmedon Permit#: 7-7 7 FROM TO I DIAMETER I TMCXr4= I MATERIAL
List all applicable wail aonsltltctran pemfts(Le.UtC,Comity,State,wame,etc.) ft. ft. in.
3.Well Use(checkwell use): �- & h-
water Supply well: 17.SCMU
FROM TO D TM S1LAWSI THICSNBSS MATERIAL
Agricultural DMtmicipal/pnblic O tt. tt. in.
Geothermal(Heating/Cooling Supply) W=identil Water Supply(single) M ft, fa.
Industrial/CommercIal lDResidential Water Supply(sbared) I GROUT
Irri ation FROM I TO MATERIAL I EMPLAcv4zNrmrmoD&AMouw
Non•Water Supply Wen:
_ Monitoring Recovery & &
Iqf ection well:
Aquifer Recharge Groundwater Remediation M ft
19:SANMRAQEL PACK(irappliclible
Aquifer Storage and Recovery 13Salinity Barrier FROM TO I MATERIAL ENW ACEMENr MMOD
Aquifer Test OStolmwaterDrainage ft. &
Experimental Technology oSubsIdence Control M ft.
Geothermal(Closed Loop) Tracer 21L DRII.LINGZOG attacb additional sheer E
1"Geotherind(HcatjgS1C9olie&Return) Other( lain under#21 Remark FROM I TO DESCRIMON eolar ,immdn sun/roek ere.
4.Date We11(s)Completed: Well W# ft'
5a.Wt:ll Laattion:
ft. &
Facility/Otwnn�er Na/mo D 0 C Facility M9(if applicable) ft. M
■rL�i—�-1e1 �.�l�✓ /ej. �Li'�iDrl► 4/ - 27 ft. ft.
Physical Address.City, d Zip ft' ft'
I / 21.REAIARSS
County Parcel Identification No.(PRO NOV 2
6b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Wong issul3cieat) 'F ION PROCESSING 22.Certification:
3�° / �1(.( �l it�v 710 9"27.D 729Y 'w �I� J-D -=-�1
6.Is(am)the well(s) rmaneut or OTemporary sr cetusea or Dan
By signing lhls form.I hereby eerbfy that the weals)was(were)constructed in acrordance
7.Is this a repair to an existing well: Dyes or 0(011*� with ISANCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,Jill out known well ronsi action iaformedonand explain the narm of die copy of this record has hem provided to the wail owner.
repair under 921 remarks section or on the back of lhisfwm. 23.Site diagram or additional well details:
S.For GeoprobelDPT 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-1 is needed. Indicate TOTAL NUMBER of wells construction details-You may also attach additional pages if necessary.
drilled:
9.Total well depth below land surface: �� ( ) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells fist all depths if different(ammple-3(2Oamul2®100) construction to the following:
10.Static water level below top of casings ZS (ft.) Division of Water Resout ,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699.1617
It.Borehole diamter: � _(in.) 24b.For Infection Wells, In addition to sending the form to the address in 24a
�o L r-f above.also submit one copy of this form within 30 days of completion of well
(Le au canny,cable, method: T�► construction to the following:
lie.auge:totetY.cable.direct Pam,�-) +(
Division of Water Resou ce+,Underg► ana Injection Central Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2769XI636
13a.Yield(gpm) f,la Meduld of test t-O r For Witter Snooty&Initicdon wells: In addition to sending the form to
the-addcess(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: lat.. vs completion of well construction to the county health department of the county
where constructed.
Foy GW-1 North Carolina Department of Ewhm mental Quality-Division of Water Resources Revised 2 22 2016