GW1-2021-00717_Well Construction - GW1_20210322

WELL CONSTRUCTION RECORD (GW-1) For Internal use Only:
1.Well Contractor Information: C
,,, ) AMES _DAhie) , ' `fit v1 14.WATE ZONES
CL`jU "1/ , 1 FROM TO DESCRIPTION
Well Contractor Name h. n.
%VC 4Zc3-�c WCAS
NC\Nell Cammuor Cenificution Number [a multi-used wells)OR LINER(if a e)
pInicft�¢It Tmu"e,`-;lii ft. b.;15 isCompany Name -1 ���/��/�r�(� �rQR T[fBING( eothermal dosed-Ion2.Well Construction Permit#:\,trrwl llo r 1 1(DtA DListn11applicable hellmnsmanivn pernirs(i.e.WC.Csnmry.Suite.Vnrianee.etc? D.
n. n. is
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO IIWIETER SLOT SIZE THIM& S!9 MATERIAL
Agricultural Municipal/Public h. h. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. n, in
Industrial/Commercial 'ffResidential Water Supply(shared) 1&GROAT
Ilri�ation FRO?I TO MATERIAL E11PI.ACE}IE`T\rEfHOD&AMlll'NT
Non-Water Supply Well: nn
LP
Monitoring RecoveryInjection Well:
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(if a blet
Aquifer Storage and Recovery ©Salinity Barrier FROM To SLIIERLIL EMPLAC&\TENT 1/Er11pD
Aquifer Test [)Stormwater Dminage n. h.
Experimental Technology [)Subsidence Control ft. n.
Geothermal(Closed Loop) [)Tracer 20.DRILLING LOC(attxh additional sheets 0necesesurv)
MOM TO It. MuirC ON lmbr,hardoecc saiVraaty nsim ev.l
Geothermal(Heating/Cooling Return)) Other(explain
�under
�#211RRe�m�arrks) h r ,
4.Date Well(s)Completed:0 -84-P.1 Well ID#Jpl (t3 n' 1 h•
t ft
5a.Well Location:
i n. n.
PadlityrOwtter Name Facility ID#(if applwable) n. h.
h.
1�I1fQ4I t�/ �CIC�RIM �Cr �RRQ�D
aa%--
Deumpbsed
Physical Address,Ckdand Zip
(%AA@mKet LASMWO149345000 21.REMARKS
County Panel Identification No.(PIN)
5b.Latitude and longitude in degreeslminutesfseconds or decimal degrees:
(if well field.a..IaVlong ei suRewra) 22.Certification:
N W
m u of enified Well Centimeter Date
6.Is(are)the well(s) JPermanent or [)Temporary
!� ,,1►�,{f B)'signing rais form. 1 hereby ceniir tMl the ae11Lq n'os Prerel ronnnreted ion n"olh are
7.Is this a repair to an existing well: ©Yes or No i lM NCAC W C.0100 or 15A NCAC 02C.0200 Well Construction Smndords and rhm o
hour Armao yell svr,mmainn in mnnrion es 1 tithe native of die o nlyofthis rerwA lms been pro,ided m the veil miner.
lJtbis is n repuir.fi l p nr
repair under 921...A..,seetioo or oa the lnvk r)rthis'fimn. 23.Site diagram or additional well details:
S.For GeoprobefDPF or Closed-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- Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
u
9.Total well depth below land surface:y �p (D•1 24a. For All Welk: Submit this forth within 30 days of completion of well
&o,,nulrlplevellali.nnBdepdmif di$erem construction to the following:
10.Static water level below[op of casing: 7U (ft.) Division of Water Resources,Infortnalion Processing Uri[,
Ifooter level it abmr.....mg.use`" 1617 Mail 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.Well construction method: FFI RR� --1NCS�A 1` construction to the following:
(i.e.auger.unary,cable.direct it 75 t
Division of Wafer Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: ..fAr 1636 Mail Service Center,Raleigh,NC 27699.1636
13a.Yield(gpm) Method of test: 24c.For Water Suooly & Injeetion Wells: In addition to sending the form to
� � the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:�t„1_� Amount:t 1 7L3 completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016