GW1-2021-02264_Well Construction - GW1_20210722

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Informadint;
ey
14.WATER ZONES
Well Contractor Name t.+�+ FROM TO DESCRIMON
NC Weft Contractor Certification Number r�rpG�'SSlC3`�Vt is.OUTER CASNG formula-cnaedwells ORLINER if Ncsble
?1+'(1L2t Q4� 4 1�Eu- �V✓ �;a,on,� FROM 4o D`AMETIIt TRlctntvE�ss� MAZBRIAL
rs ;:t F+� Of H S tt �z in 'Tit/
Con4my Nate 16.INNER CASING OR T4IBING at etwed
2.Well Contraction Permit#• ��� PROM To DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(Le.UIC,County.Siatte,Variance,etc.) fL ft. in.
3.Well Use(check well an): fL ft
Water Supply well: FROM REETO I DIAMETER SLOT SIZE TMCKNMS MATERIAL
]Agricultural QMunicipaUPublic 45 s tt S S it , is 0(a 5"r—k 40 Pv c
Geothermal(14eating/Cooling Supply) [)Residential Water Supply(single) tt g, i lm
1nduStrial1C01uM etal [)Residential Data Supply(6haled) IL GROUT
74
tioa FROM To MATERIAL EMPLACEMENT METHOD&AMOUNT
Non water supply wen: Q ft. ft `�� f�t3 v�i✓�
Monitoring . Rxovt ry tL fL
20jection Well! it. rc
Aquifer Redbarge QCuoundwater ltomediation
19.SANDIGRAVEL PACK a le
Aquifer Storage and Recovery [)Salinity Barrier FROM TO MATERIAL EAff'LACEMENT METHOD
Aquifer Test QStaamwater Drainage a e ft 0 ft / 4*jzl gl L. P(91 P C&
Experimental Technology QSnbsidence Control fL
HGeothermal(Closed Loop) [)Tracer 20.IIRiLLiNG LOG faftch additional sheets if
Geothermal(Heatirt Coolie Return) nother lain under#21 Remarks FROM TO DESMIMON color,hardnets,saWroek fte,grain thr,etc.
O "IL to I R' 7'cr.P Sol
4.Date Well(a)Completed: /�9/ [Well m# ------ t,ft- L-5 ft- A4- a p4e I<
Sa.Well Location! ,S fL 2 8 ft- Q k!Gy 9I416 Clam ft t eC
ROBERT V`AL&�.t-rl11>E �S n �1.5' � �rtRC,Y CLlW 15ri 6 L4V&kS—
Facility/Ownar Name Facility WN(if applicable) 145 R 5Z IL e-o r*rL 5 e_ SA-µ b
/63 NQ.txv�(. sY d IFP.TFor,6 AtC. a,-794�� .5z fL60 fLs�iLL-L l art & S/�t�0)
physical Address,City,and Zip &0it• q© W s*{6.LL t'--t_A vvL C
S It.REMARKS
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/ndnnterAeconds or dedmal degrees:
(if well field,one laNlong is sufficient) 22 Certification:
N774 . Y53 , � W Pin
6.Is(are)the well(s)J/Permanent or Temporary Signature of Certified Well Contractor Date
��� ....,,,,����,,,,cccc���� By signing this form,7 hereby cerlfjy that the w fl(s)war(were)constructed in acaordatce
d
7.Is this a repair to an existing well: [)Yes or No YM ISA NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Rwdards and that a
If this is a repair,fill out known well construction information explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarkr ration or on the back of this farm.
23.She diagram or additional well details:
8.For Geoprobef[PT or©oged-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I GW-1 is needed Monte TOTAL NUMBER of wells construction details. You may also attach additional pages if neca5ary.
drilled: SL_IH141=AL Il�iSTRIICTLOL�tS
� I
9.Total well depth below land surface! qG 00 24a.For All Wells: Submit this form within 30 days of completion of well
For muhiple UVlh list all depths tfd($ereat/example-30200'and 201005 construction to the following.!
10.Stage water level below top of easing: (lit) t)ivisloa of Water Reson
nt
,fader level is above casing,use"+" t r 1617 Mug Service Center,Information
Raleigh,NC 270961617
11.Borehole diameter. (in.) 24b.For Injection Welts: in addition to sending the ftnm to the address in 24a
12.Weil construction tDetbod: Ul� Rp`�Q/Z V above,also submit one copy of this form within 30 days of completion of well
construction to the following.
(i.e.auger,rotary,cable,direct push,etc.)
i
Division of roster Resources,Uirdergr ound Injection control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 i T
132.Yield(gpm) �-5 Method of test: L;V4 1 241 For Water SDDD(y At t?iection Wells: In addition to sending the form to
G AAC_I U A& k41 p0 CAL©R.L rE the addresses) above, also submit one copy of this form within 30 days of
13b.Disblfeetion type: Amount: aZ completion of well construction to the county health department of the county
where consttucttxl. i
Form GW-1 North Carolina Department of Eavimnonental Quality-Division of Water Reso'uroes Revised 2-22-2016