GW1-2021-00003_Well Construction - GW1_20211209

Pjirtf Form
NNTLL CONSTRUCTION RECORD(GW-1) For Insp tal Use Only:
1.Welt CnatractorImformatioa:
I4 WATERZONFS _
FROM TO D85CR1P7IOPi
71672
1_,kLWC LA, �> ft
NC win 15 OITIERCASIIYG'forgal cased wens 4 R1.JM It d livable
c- - c C FROM TO DIADIK THICIni tFSS MATERIAL
`.� as.u+Irll;recnsnvGoxTUs closed-1 6' -
FROM TO D1AiniTER Tnit3CD]FSS Mt+TExrnt
3.�Yt~llCons+s••�ctinaBermi#:—.': � R in.
I.LK all applicable melt cor-mucrioagerrr-its Le.UIC,Cerx*Stat4 i%mc++rp ere)
3.Well Use(chw-k-well use):
Water Supply Well: FROM To DIAMEt&R SLOTsmE TffiCitNESS asATEniAL
Agticult l Muoicipal/Pnblic ft % in
Geothermal(HeatinJCooling Supply) Residential Water Supply(single) fL ft, in
IndusaiallCammercial Residential Water Supply(shared) 1&.GROUT
lIii?atiom FRONT TO - MATERML. El1MACEi<TEPIT rdMOD&A'KOEnvT
Non-Water Supply Well.- ® ft. = it ,., G
iVlonitorins ORecovcty ft ft
Injection Well: R it.
AquiferRecbzrge GroundwaterRemediation g / yANDGRAE PACK Ie - .
QiAquiferStoraggeandRecovery DSalinityBarrier FRoaT To MATERIAL . aTsiaon
Aquif�-Test OStonnwaterDrainage fL M
Experimental Technology 13SubsidenceControl ft
Geote�al(Closed Loop) [3Tracer 20.I)12ILI1NGLOG atffiehaddI$oaatslieetsifu "
FROM TO DtsSCR1PrmQR(colo,hscdness.3oHhx1• 4- slzyltn)
lGeoAmerm-laleating/Cooling Rettnn} Other(explain—der#21 Remadts) #t ' (r. >
l
4.Date Well(s)Completed= ) Walt IIYR 0 U)D,71['� ( ft C
52.WellLocgdon: •a ft ft ` ft J
&
ta_ ;Q�d'?k�e FactlitylD#(Ka+?plicable)
s `r
i\ ft ft
Papsf!-" C�,and Zip
��i&3U-M zl.IZEn RIcs
Parcel IdenFifreationNo_(PIN)
So.Latitude and longitude in degreesimminuteslsmands or decimal degrees:
:s S.FIIcielLJ 22.Certiffe tiom
N W
c Is(are)the w (s) Permanent or Temporary
Si fate ofCerii&ed Well Contractor Date
B!'sigrsing this form,I iu3eliy cetYrJy flint the tivelt(S)Sias(rcere)constructed in accordance
�. rr is< <p_to ar cfi ne well (')Yes orV.Dxphdn
o A134_WCAC 02C.0100 or 15ANCAC 02C.0200 well Construction Standards and that a
sj 1 i is c r u c�=�.s-:+•e= c.a-&vvionn tinfarmation the miure of the COPY ofth&record t:as been oravided to the well aivner.
TeP ME, er=;;.==_ oroa:re back tfthisform. 23.site diagram or additionalwell details:
You may use the back of this page to provide additional well site details or well
S.For GeoprobaTYT or Ciase&Loog.Gent herm it Wells having the lama
construction,on y 1 GAF i is needed.. indicate TOTAL 3� AMER of wells
constriction details.You may also attach additional pages if netssary.
drilled: SUBMMALINSTRUMONS
9-Total wen depth below land surface: i l 'P A) 24a, For All Wells: Submit this farm within 30 days of completion of well
For Laaildaisi;ai '!--.ttPte1l39-i00'and2W00) construction to the following'
10.Static water level below tun of casing: "Y� + (ft) Division of Water Resources,Information Processing Lint,
If ureter lem,is above C=irg use`=" 1617 Mail Service Center,Raleigh,NC 27649 1617
n.Borehole diameter. Czm) 24b-For Injection WeUs In addition to sending the form to the address in 24a
t above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: r, r construction to the following:
(Le.auger,rotay,c_ble,dirt o-sh a-}
' Division of Water Resources,UDdergrommd Injection Control Program,
FOR WATER 5U-PPLY WELLS 04MY 1636 Malt Service Center,R21*.h,NC 276991636
13a.Yield(gpm) Z(5 --- Methodeftest: Ntter� ?Ae For iitater SnpDly&I.niection 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 1 completion of well construction to the county health department of the county
where constructed.
ouality-Division o£Water Resources Revised 2-22 2016