GW1-2021-00683_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATIMZOP S
Well Contractor Name
FROM TO D99011 TION
-loyz
NC weft Cant eotor Catifl.b.Numb.
.' t ' S.O LCAQ r mortt�eascA we 1FRUCKNE8119
LIIYSH IIieble
�Oi�T IN I GGlI��S f�/LG. FROM TO DlAbn M MATERIAL
ft. ft.
Company Name App����yo� � �
to
16.llYP1ER CASING OR TUBING thermal dosed-ioo
2.Well Construction Permit Z) L,5•/ FROM I TO I DrAmum I TmcKNESS MATSitrAL
List all applicable welt construction permits i e-UIC,C00%Slate,var(amce,etc.) ft. ft. in
3.Well Use(check well use): ft. f.I in.
Water Supply Well: 17.sCrtBEN
imom TO DIAMETER SL"TSI2E TJHCENESIS MATERIAL
Agricultural E3M icipaVPublic p fa FL im
Geothermal(Reating/Cooling Supply) dential Water Supply(single)
ft. ft. im
Industrial/Comm=W DResidential Water Supply(shared) M GROUT
Trri ation FROM TO MATERIAL I EMNACEMENrMnNOD e:AMOUNf
Non-Water Supply Well: LQ ft. iR. o9
Monitoring DRecovery & &
lujection Well:
Aquifer Recharge 13GroundwaterRemediation
19:sANDMRAVEL PACK a lteable
Aquifer Storage and Recovery QSwinity Barrier FROM TO MATERIAL EMl%ACEMXKr MHTHOD
Aquifer Test ostormwater Drainage ft• ft•
Experimental Technology Dsubsideno Comm, rt; et.
Geothermal(Closed Loop) OTracer a DRMMG LOG attach addition d sheets ff
IGeothermal eatla Coolin Retain Other( lain under#21 Remarks TO DIiSCRn'TTION color soilfiodc
ft. fG
4.Date Wells)Completed: 1 I -g�,j Well M# ft•
P.
$0.Well Locatlon: Aft ft'
0.
Facillty/OwnerN Fac➢tityID#(Jfappliiable) M %
1, z%&-66je., 11c, % ft.
Physical Address.City. ft. ft•
►=tr��,1��'H 21,RMARS3
County Parcel Identification No(PIN)
8b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one latliong is sufficient) 22. n:
1,00,
I y
6.Is(am)the wells) ermanent or OTemporary Certified Well Date
repair By signing this form.I hereby aerfib that Jhe MR(s)rvar(were)constructed in accordance
7.Is this a to an wells Yes Or o with ISANCAC 02C.0100 or ISANCAC 02C Moo Well Construction Standards and that a
If this is a repair,fill out disown well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
repairunder#21 remardssection or on the back of this form.
23.Site diagram or additional well detan.c:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may=the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction detads..You may also attach additional pages if necessary.
drifted: +� $LiR1t+fl1TAT.I1ILCTRii(Ti�NC
9.Total well depth below land surface: yqp.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dii Brent(example-3@200'and 2@1005 construction to the following:
10.Static water level below top of easing: ?_ (ft.) Divlsion.of Water Resources,Information Processing Unit,
If water level is above caring,use"a." 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: &Zg 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 conshwilon method: construction to the following
CLe auM rotary,cable.direct push,etc.)
Division of Water Resourees,Underground Igiection Control Program,
FOR WATER SUPPLY WELLS ONLY: �f 1636 Mail Service Center,Raleigh,NC 27699.1636
13a.Yield(gpm) /O Method of test 1614w,+ 2I/r► e.For Water&at&Inimmon Wells: In addition to sending the form to
address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amounts �, completion of well construction to the county health department of the county
where construc to
Form GW-1 North Carolina Department ofF.nvirontentai Quality-Division of Wateritescomes
Revised 2-22-2016