GW1-2021-00063_Well Construction - GW1_20211109

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1,EContractor Informa6ton:
14:WATER ZONES .
Well ConhactorName FROM To DffiCRIPI'ION
NC Well Contactor Certification Number i6:OUiSR CASIIYG' rmotd casrbA we OR LIIYSR N ncubic)
FROM TO DIAMETER I TRICKINESS I MATERIAL
in.
Company Name 16.INNER CASING OR TUBING(eothermal closed-loon)
2,Well Construction Permit : FROM I TO I DIAMETER I TIUCKNM I MATERIAL
List all applicable well construction permits(i e.UIC.County,State,Variance.etc.) ft, ft. in.
3.Well Use(check well use): ft. ft. 1D
Water Supply Well: IT.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 13M al/Public 0 fL ft, rn.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. hL
Industrial/Commercial DResidemial Water Supply(shared)
18.GROUT
"IrriRation FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNr
Non-Water Supply Well: ft. ft
Monitoring ecov ft. ft.
Igiection Well:
_ A uifer Recharge ft q echarg }Groundwater Remediation
Aquifer Storage and Recovery 3a1 Hamer 19.'SAND/GRAVEL.PACK a usable
rarity FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology 13Subsidence Control ft. ft.
Geothermal(Closed Loop) E3Traccr 20.DRILLING LOG(atachadditional sheets if necessary)
Geothermal eatin C oling Return) l Other(explain under#21 Remarks FROM ft. ft.To DESCRWnON color,hatdnem solUlmk sm etc
IL�
4.Date Well(s)Completed: y� Well ID#
Sa.'6 e11 Location:
ft. ft.
Facility/owner Name Facility ID#(if applicable) ft. ft
NOV
,57q r,, r—ay- w� Tfw�b .� 6 ft. ft.
Physical Address,City,and Zip ft. ft. DVVR SECTION
n
1Je r]GD 21.RLMARHS
unty Parcel Identification No.(PlN)
5b.Latitude and longitude In degreeslminutes/seconds or decimal degrees:
(ifwell _pld,one laatt/�long is sufficient) r�/�� �7/� 22.Certification:
6.Is(are)the well(s) rmanent or Temporary
Signature of/Well Contractor Date f y
By signing this form,I hereby certify that the ue11(s)was(were)constructed in accordance
7.Is this a repair to an eidsting well: MVeser ONo with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
1f this is a repair.fill out ktown welt construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remark section or on the back of this 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 sik 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: r SUBrt1I1T"I'Ar-I%irsTg r(�rrCENS
9.Total well depth below land smffaee: o (tT.) 24a.For All Wens: Submit this form within 30 days of completion of well
For multiple wells list all depths if dent(example- Q200'and 2@100) construction to the following:
10.Static water level below top of casing: t�G� ft) Division of Water Resources,Information Processing Unit,
tfwater lever Is above casing,use•+- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24b.)For Iniection 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: construction to the following.
(i.e.auger,rotary,cable,direct push,etc.)
Division of Wafter Resources.Underground Inflection Control D.-o8 m,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service'Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of Msti D 24c.For Wailer Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Dislnfectlon type: A>ltmmtt» O completion of well construction Ito the county health department of the county
where constructed.
Form WW-1 North Carolina Depa mrent of Environmental Quality-Division of Water Resources Revised 2-22-2016