GW1-2021-00411_Well Construction - GW1_20211206

WELL CONSTRUCTION RECORD(GW D For Intem&use y.
1.Well Contractor Information:
Well Contractor Name FROM TO D ON
>t:;
NCC Well Contractor Certifies tionxumber (�,� q
"eAJa P- 'l L;t AUVAI CJ4'111 i A C l n C- . FROM To arA%t �ciavEss MA
Company Name �t
2.Wen Construction Permit#:00 a Oa k — O© i-(0 4 ttROM To DIAMETER THCB:NM MATEttIAL
List all applicable%well cowiruction penults(i e.UIC,Cowity.State,irarf-m etc.) R R in
3.Well Use(check well use): fL �' is
Witter Supply well: FROM TO aIAMErER sr.OT sEM 'rHwxNrLss MATERIAL
Agricultural OM bilk tt. ft. in
Geothermal(HeatinglCooling Supply) OfRes Water Supply(fie) tt. tz 1n
Industrial/Commercial DResidential Water Supply(shared)
hri 'en FROM TO TERIAL EMPLACEMENT METHOD&AMOUNT
Non�water Supply well: - 2 & P�2 � $ SO
Monitoring Recovery
Injection well: >n ;
Aquifer Recharge OGre�undwater Remetliation
Aquifer Storage and Recovery 13S81IDlty Barrier :FRO4MTO MATERIAL EMF4ACEMENTMot MOD
Aquifer Test 13S Drainage ft.EvelimeatalTeeehnology DSobsidence ControlGeothermal(Closed Loop) 13Trscer
Geothermal Coo' Retmn Other lain under#21 Remarks FROMI o. DEseRlPrtox cuter aotthoet eta
© ' 3fLy-
4.Date Well(s)Completed:' 3 d Z wen ID# ft. �3 v N'
Sa wen Location: 01�p CD
(O D c; �.� a�3 �� Jar bt✓,.�
Facility/Crwmer ame Facility lD#(if applicable)
it. it.
Address,City end Zap � � R. 11. � 4 �- ` •, ,
County � Parcel Identification No..(Pm
Sb.Latitude and longitude in degreaJminuteslseconds or decimal d4grm:
(ifwellfield,one tatlbngissufficient) t/ 22.Cerdfleation:
35° 3o ` N3 / gL4.g w $ �D d,-
CID
6.Is(are)the wen(s)�rmanent or Temporary Sigoatuee of Certified Well Contractor
�. By signing this form.I hereby certify that the well($)was(x�ere)eotutructed in accordance .
7.Is this a repair'to an eAFfing wen: OYes or:�1VO wlth 15A NC.IC 02C.0100 or IJA NCAC 02C.0100 Well Construction Smndmds and dwt a
Ifods is a rqm&,lU out brown well consbucV-Woranai m and ezp/ahs ere rwtror of the cqy of d*record has been provided to the well owner.
rrpair wider#21 rmm*section or an the back ofdds form.
23.She diagram or additional well details:
You may use the back'of this page to provide additional well site details or well
8.For GeoprobeJDPT or Closed-Loop Geothermal Wells having the same
conetiudion,only 1 GW 1 is needed. ladicate TOTAL NUMBER of wells constructionYou may also attach additional pages if necessary.
drilled / SUBM1TTA1 INSTRUCTIONS.
FJ M,
9.Total wen depth below land surface: (L) . 241L For All Wens: Submit this form within 30 days of completion of well
For md*k%rlir list ay,depths if dl�'ere d(erantple-3®200'and 2@100) construction to the following:
10.Static water level below top of cuing: ow Division of Water Resources,Information Processing Unit,
if water level is above easing:use"+" 1617 Man Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in 24b.For Injection 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.wet eomtracdon method: construction to the following:
(ie.auger,rotary,cable,detect inter,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Man Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm) S-O Method of test: ell,
S- 24c.Yor Water Spuniv di:Iniection-wells: In addition to sending the foam to
the address(es) above, also submit one copy of this form within 30 days of
13b.DlsWmdon type: T Amount I 0 completion of well construction to the county health department of the county
where cpnsttucleed.
Form GW-1 Nord,Carolina Department of Environmental Qmlity-Division of Water Resources Revised 2-22-2016