GW1-2021-00446_Well Construction - GW1_20211206

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only: —
1.Well Contractor Information: -
%34<WATER'ZONFS
J9 FROM TO DESCRiMUN
Well Contractor Name �(� ft. 2 ft
& J ft. -
NC Well Contractor Certification Number 15:UUTERiCASfNG toR':ina7li mead wells iORLiNE1L' a' cable
p FROM TO DIAMETER THICKNESS MATERIAL
Company Name 416 111INER'CASING.OA:3(TB[NG:`' thertileldsedl z ..::.
2.Well Construction Permit#: /f 6 1 a to U FROM - TO DiA1NETER THICKNESS MATERIAL
fL ft. in.
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc) { in.ft. ft.
3.Well Use(check well use): r1WSCREErit
LInd
Well: OM TO DiAMErER SLOT S12Z THICKNESS E)Municipal/Public p &(Heating/Cooling Supply) Residential Water Supply(single) fL ft in
ommercial Residential Water Supply(shared) 'GRoOI 1 •<'`FAOM 'I'METHOD&AMft.Non-Water upply Well: .
Monitoring Recovery R R'
Injection Well: R• ft.
Aquifer Recharge �GroundwaterRemediation 19_$AN11/GRAYE1.PAt;K ifa licbk =
Salim Barrier FROM TO MATERIAL EMPIACLEMENT MET90D
_Aquifer Storage and Recovery tY &
Aquifer Test D Stormwater Drainage
Experimental Technology, oSubsidence Control R
Geothermal(Closed Loop)
Tracec 20.DRI1LINC'+LOG`idhiehadditlonalahtefditnece!
FROM TO DESCR�7'ION robs hard eoWroek • etc•
Geothermal eatin Coolin .Rettun -.Other(explain under#21 Remarks) -O & 7 tc t a t:J C
fa to S
4.Date Well(s).Completed: wen uD# 79
/ fL Z ft., r �-
5a.Well Location: fu fa
ft. ft.
j Fatuity/Owner Name Facility b#(if applicable)
ft. ft.
>9Ci �yzs76
ft. &
Physical Address,City,and Zip , _-
731vRENfi►RiFB
sty Parcel Identification No.(PIN) rt
l
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 Certiticati
- (if weU-Btl4 one taVlongis-saffideat) -- — ----
c J—r_zt t e`r 6 .' Z 2,3 31 _W
Si ofcertiS it contractor Date
6.Is(ere)the well(s) PI'rntanent or oTemporary
By signing this form,I,hereby certify that the well(s)was(were)constructed in accordance
7.Ts this a repair to an existing well: Yes or t 'V with I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy al thisom been provided to the well owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
! 8.For Geoprobe/APT or Closed-Loop Geothermal Wells having the same You may use the back of this page t provide additional well site 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: SUBNIITTAL INSTRUCTIONS
9.Total well depth below land surface: (fL) 24a.for&I W"- Submit this form within'3Q days of compleptn.of well
le-3 00'and 2
For multiple wells list aff depthy if dl,QererU(erbmp �� construction t0 the following:
7,.p (ft) Division of Water Re'sources,Information Processing Unit,
10.Static water level below top of casing: 1617 Mail Service Center,Raleigh,NC 27699-1617
Ifwater level is above casing,use
� 11.Borehole diameter: 9 24b.For In*ection Wells: 1n 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: r�/. construction to the following:
(Lt.anger,rotary,cable,direct push,etc.) r Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a Yield(gpm) Method ottest: 24c.For Water Supply&Infection Wells: In addition to sending the form to
u the address(es) above, also submit one copy of this form within 30 days of
d3b.Dlsinfect. type: t Amount' d 7 D Z completion of well construction to the county health department of the county
where constructed.