GW1-2021-00201_Well Construction - GW1_20210125

WELL CONSTRUCTION RECORD (GW-1) For Internal I, se Onl}
1-Well Contractor Information:
( IM t<1v J f "Sllsh uwAT6R2ANFS
uril cont2aor\am Faovf ro DFSCRIPrws
R (� ft ::clllye folLi f�melty
91�`1B lt.tt
l� fL —r L, fL ol2i:/ j/ten i/w cAc:
NC`6Coaaactor Certification\umber 15.OUM CASING for 0R3.1�R
rarC Ji.l 2r✓i L( cn FROM TO DIAMETER TRICKN'EES MATERIAL
C $ d CLas{reel/cA ( C ( f l n. ) ft i I I1,I in, st1 W rvc
Company Name ,..
16.DVNER CASR+R:OII 111RRPG' -:�'• �:i�.iti. �:-.:,
2.Well Construction Permit#: ,2qq o y 3 W yijg 14 3 iRON TO DLAMETER TRICKYESS MAlE0.1AL
Osr ail applirable well rnns:ruruon permits ri s.C!C.ce karc.siimvr,err., ft R in.
3.Well Use(check well use): tL fL in
lGeothermai
ater Supply Well: IL.SCREEri ::::. -
FROM TO DIAMETER SLOTSRE TtIICKNE55 MATERIAL__
Agneultural [3mumc:pal publie fL bu in,
�17 to l yt Oc8 kti c ✓�
Geothermal(Hea¢ne Ceohne Supplyl rRResiden ial Rater Suppll (sm¢ie` R m
In hismal'Comn ii []Raside,,'a:Rater Suppl_ (shared. 15:GAODi'
Irrigation ET TO yyMATERIAL EMPLACEMENTMETROD k AMOUNT
a-Water Supply Well: O R I-'1 fL .Moniroring �Reco.enjection Well: R fL
.Aquifer Recharge OCroundwate:Remediauon19.SAND/GRAY$h PACK..AquifrrStorageandReco�er. OSalimn Barrier FROM TO NATERLAL EMPLACEMESTMMOD
Aquifer Tes: OStomwaier D.rainaae i R. Z R /
� 17 ( i � i SAkqExperimental Technolog+ []Subsidence Control fL fL
Geothera (Closed Loop) OTracer 20.DRILLING LOG(Heatme Cooling Return; Other(es lain under=21 Remarks) mom to DESCRIMON(mkluNo .,rock
\ aia,ev7
o
( R 2 f
4.Dam Wells)Completed: II�1� Well IDk R R l S�rCI 5 Sa.Well Location: I
R
( Pftn Rldae R R
Fac,hiv,Owner Name Facihp!D=(if applicabitl R ft
131'1;( F..lk (Lpc- k C ,;Ila 27127 R rc
Physical Addms.Cin.and Zip R ft
I
'ZL BP.IfARKb. .: r
l.arn4,AcK ca7A4:z4ccc9ccc; ,,s,t `
Coven Para de oficavion]o.(PI\1 Aol5ieel 11v LOwf""'e �r+2in PY Cp:v bark+r
5b.Latitude and longitude in degrees/minutesiseconds or decimal degrees: left Far CC r F 4 t.I
(if well fell one lat9one is suffioenp P_.Certification:
p l
3� 32 s1 1s 52 zs W 7z. %;
6.Is(are)the well(s)UPermanent or []Temporary' Srenan�u -i'Zobfied well Cerntractcr Dne
f .+gmnR rhu/n l h e.n•;ter T rhea the .ur(tt.+uuv(were,n+nvrwnQ in aecorrla¢e
7.Is this a repair to an existing well: []Yes or CfNo th 154 NC'AC 02C 0ira,cr I54 cCAC 02C 02(X Rill Corunurllon Slw ds and,hw a
!!/tF,ir u a repair�'".ou;umvn»ul cnris'rur +r. n/+rm¢+n..r�e.ii..tic _ - ', l.0 rrru -'¢ earn pr.,.:xC n he well nwrzcr.
repair urNer tl2l remark)senior.nr on ue Aoc(nJthb,brm.
- 23.Site diagram or additional well details:
B.For Geoprobe/DPf or Closed-Loop Geathermal Wells hai ing!he same }oc mac use tte'Dac of this page to aocide additional well site details or well
construction,onh 1 Glf-i is needed. Indica-e-C-.A NUMBER of wells coosm ction derails. You Tar,a:so attach additional pages ifnecessan.
drilled. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: aO k� 24a. For All Wells: Submit this form within 30 days of completion of well
f or mu[riple sod[alur al[depths�Qd rent frsamplr-?�Z00'and2e�100') `l)l constuction in the following
(1 �l
10.Static water level below top of rasing: _J (ft.) Division of Water Resources,Information Processing Uldq
If„a+er level Ia¢hove rmlrg.:..c-' 1617 Mail Senice Center,Raleigh,NC 27699-1617
11,Borehole diameter: (in.! 24b.For lniection Wells: in addition to sending the tom to the address in 24a
i rz digit p,uh.etc.)
12 We6 coos[ method: v5 L f
above, also submit one cop, of this form within 30 daps of completion of well
auger.rorarv. hie,ci
_ t onst;.rc!ton to the follow'mo
ryo�\ -
/ 6 Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: N I 1636 Mail Senice Center,Raleigh,NC 27699-1636
1` 13a.Yield(gpm) Method of test: aP M k) 7.4c. For Water Suppy B toiection Wells: In addition to sending the forth to
the address(es) above, also submit one cops of this form within 30 days of
13b.Disinfection type: HT L amount: i•.y C> 1- rompletion of we![ construction to the count, health department of the county
where constructed.
Forrn GW-1 \onh Carolina Departmentof Environmenial Quahn Divisionof0.-am7 Resources Reused 2-22-2016