GW1-2021-00099_Well Construction - GW1_20211109

♦r L'LlLI X% lIVlyu For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well
\Contractor Information: I
To r tv I ' 1 / 1 (A �1• S FROM
WATER ZONES
� FROM TO DESCRIP770N
Well Contractor Name ft ft. ) .20
0
0 3 i ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING'for ulti-cased wells OR LINER rf a' ltesble
FROM TO DIAMETER THICKNESS MATERIAL
1 4:5 I.v 2 �.L- r 1 O ft. (o n G ! In.
Company Name %` 16.INNER CASING OR:TUBING'(geothermal closed-loon)
// FROM TO DIAMETER THICKNESS IA MATERL
2.Well Construction Permit#: (O 2- 3 % ft. in.
List all applicable well construction permits(i.e.County.State.Variance,ere.) fL ft in
3.Well Use(check well use): 17.SCREEN -
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
OAgricultural OMunicipal/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) Weidential Water Supply(single) fL ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation Q `t' A6 rL �P/p 0 T-e OUR ecl
Non-Water Supply Well:
❑Monitoring ❑Recovery fL ft W*
Injection Well: ft. ft' Q
OAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK fa ble
OAquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO R MATE,i RIAL F EMPLACEMENT METHOD
OAquifer Test ❑Stormwater Drainage
fL ft.
OExperimental Technology ❑Subsidence Control
20.DRILLING COG atmcb addltional sheets if races§a
OGeothermal(Closed Loop) OTracer FROM I To DESCRIPTION(color,hardness,soiVroek typt,grain sin eta
OGeothermal(Heating/Cooling Return) OOther(explain under#21 Remarks) R ft P 01 CI 4
4.Date Well(s)Completed:_ ! Z 6- A o ft•
5.Well Location: IYA
RobexTe Ayaetl tLgn�e � too Sao rL AMe
Facility/Owner Name Facility ID#(if applicable)
fL fL
( 7/8 CI4ICRUf�A� ,C�INe. fL ft.
Physical Address,City,and Zip
21.REMARKS'
U/u,ho ru
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tat/long is sufficient) INFORMATION PROCESSING UNIT
3q
411 7J232� 23 N -- �1,F Y W 4C& rn,
Si ature ofCenified Well Contractor' Date
6.Is(are)the well(s): BPermanent or OTemporary By signing this form. 1 hereby certify that the well(s)was(were)constructed In accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Ko copy of this record has been provided to the well oiwher.
If this is a repair,fill out!norm well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supphy wells ONLY.with the same construction,yotr can
submit one form. 24.Submittal Instructions:
/� i
9.Total well depth below land surface: 39,6 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifili ferent(example-3ta 200'aatnd 2@100) construction to the following:
10.Static water level below top of casing: TS (ft) Division of Water Quality,Information Processing Unit,
1j outer level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
i
11.Borehole diameter:_- W (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: /�}% construction to the following:
(i.e.au ge rota able,direct push,etc.) -
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) O Method of test: ilia 24c.For Water SuoDly&Geothermal Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
13b.Disinfection type: Amount: ��.1�,T IVTS where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013