GW1-2021-00723_Well Construction - GW1_20210322

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
eA L6 1 1 14,WATE ZONES
FRONT TO DESCRH'IION
Well Conflict.,Name n- n.
NoVJC I4M3� B. rt.
NC Well Contractor Cer ificati.n Nitrate, 15.OUTER CASING(for multitased wells)OR LINER Id a OcabiTER
" FRONT TO DLUIETER nBCSNTSS NL\ IAL
Company Name L_. 16.INNER CASING OR TUBING(geothermal dosed-too )
2.Well Construction Permit III: FRONI Trr Dt VKETER TmcKNEss NUTERIAL
Liv all applicable well amfelnm,ion peon,fie_UIC Culan" Starr.Vora anue.'I,%I
n. a
3.Well Use(check well use): _
F
Supply Well: IT-SCREEN
FRONT TO DLNIETEIt SLOTSIM THICKNESS NATERIAL
MunicipaliPublic ft. ft. in.
Hearin JCooling Supply) Residential Water Supply(single) n. fL in
mmercial Residential Water Supply(shared) 1B.GROUT
FROM TO MATERIAL Llll'I.AC-ENIE1l'\IEfNDD&.XNIOUNT
Non-Water Supply Well: n. -) If-
Monitoring Recovery ft. n
Injection Well: n n-
AquiferRecharge ©Groundwater Remediation
19.SAND/GRAVEL PACK(ifa 61e)
Aquifer Storage and Recovery Salinity Barrier FRONT TO NUTERIAC ExmLACENIENT METHOD
Aquifer Test [:)Stormwater Drainage ft. R.
Experimental Technology DSubsidence Control B. It.
Geothermal(Closed Loop) QTracer 20.DRILLING LOG(atmch additional sheets if ni r )
FRONT TYr DESCRIPTION lrabr,MNn.c sdYmh t, u,etc-1
Geothermal(HearingiCooling Return) Other(explain under#21 Remarks) O\ n. 1 4' B.
4-Date Well(s)Completed:( 13_�1 Well IDtt H B' ft. 'O e
I-
D.
5a.Well Lortation: Low
Mal( i An ,1(�cQ NA r�
Yl r RY(
Facility.Ownet N:unc Facility ID#` J (if applcablc) �
❑. n.
� 41k, �t NC. tSQ(`4 n. ft.
Address.City.:md Zip
CA21.REMARKS
C.unO Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
l ifwell field one luubm;is suffiewrl) 22.Certification:
6.IsOrt)the well(s)4YIPermmnenl or DTemporory Sign tom.f Ccmficdw'ell Commas Date
B,. gning obis furn�. I herrbr mnif'rho the ue/1W...1,forrru rams u,'M to arcnalun<r
7.Is this a repair to an existing well: ©Yes or No I I5A NCAC 02C.0100 or ISA NCAC 022C.0200 Well Gmsoumlan Sondnrds Io, n
1Jrhi.s is n repair.fill ou,knmrn yell mnvnmfion influx, inn n, e.plain,hv ,orate of I1v, '!^pe of this retard has horn pnn-iJed m the nrll nn.mr.
rrlxiir uader921 rrrnnrkv srmion or nn,he&u k,Jlhh f mr
23.Site diagram or additional well details:
S.For Geoprobe/DPT 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 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: j SUBMITTAL INSTRUCTIONS
K^�•1
9.Total well depth below land surface: ' rb (ft.) 24a- For All Wells: Submit this fore within 30 days of completion of well
Fonrudriple ve/ls ho all depths ifd f,,al(emrrrp/e-3u200'and_ar 100') construction to the following:
10.Static water level below top of casing: 1 ut (D.) Division of Water Resources,Information Processing Unit,
If.,mer lerrrzs aMrer ufsing.use"•'- 1617 Mail Service Center,Raleigh.NC 27699-1617
11.Borehole diameter. l-t[ (in-) 24b,For tnieclion Wells: In addition to sending the form to the address in 24a
Js I ` - above. also submit one copy of this forth within 30 days of completion of well
12.Well construction method: f{1 1Z KtsA- !m ft construction to the following:
li e.auger.rotary.cable.direct push,etc.
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: AA 1636 Mail Service Center,Raleigh,NC 27699.1636
13a.Yield(gpm)P1 Method of test: H r)Z 24c.For Water Suri & Infection Wells: In addition to sending the form to
fir, the address(es) above, also submit one copy of this form within 30 days of
m
13b.Disinfection type:� 1�.11f Aount:y5l I completion of well construction to the county health department of the county
where constructed.
roan G W-1 Nonh C: lina Depanment of E.rimnraenial Qwlity-Division.f Water Resources Be,ised 2-22-2016