GW1-2021-01208_Well Construction - GW1_20210323

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
I.Well Contractor laformatlou:
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Well Contraccr Name Q.1{1 "°,\ ( 'tl\ ,) PROM lY1 ES
DF2tCRIPfiO\
LISIA1 R. R
NC Well Contractor Cenifirwion Numbcr ,A^7� 2 3 2021 15.OUTER CASING far mW-cared welt OR INNER
NA'
1 1VIH TO DIwME1PA TIIR:101B45
V. AAIAL
Fronl W�l� CO 1Uq
Company Name 1T f
3 � � O`P 1�1,� ` ' -;'CI IC INNER CASING OR7VRING
2.Well Construction Permit 0: a �' "; PROM TO DIAMEfEH TIDCIU:E55 MAi[rnAL
Lul al(applira6le ne/!mmrrurnnn peewits ri e.UIC.Cnunpt State.Pariamr.etc) n. R ra•
n. fL is
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM I l'O I DIAMgtP3 SLOT 61]E TRICTUIFSS MAlER1AL
CAgricultuml OMm�unicipaVPublic n. fL is
ClGcothermal(Ileating/Cooling Supply) HResidential Water Supply(single) R R fa
Olndusnial/Commercial UResideatial Water Supply(shared) 13.GROUT
Ejbnxgtkm OWdis>IOD000 GPD PROM TO I M,hTEn1AL I Pl4PLALR1agNTMYN00a AMOUNT
Nou-Water Supply Well: G R ab 'L C(eIlye"re
OMonitoring ❑Recovery fL R
Injection Wen: R R
❑Aquifer Recharge OCxourldwater Remcdiation
19.SANDMRAVEL PACK imW
OAquifef Storage and Recovery OSahnity Barrier FROM TO MATEmAL EMPLACFMPAT MgrNOD
DAquifer Test ❑Stonawater Drainage R R
❑Fxpnimental Technology USubsidence Control R n•
OCFeothermal(Closed Loop) OTmccr 20.DRILLING LOG alkeh"ad ..
OGeothermal(Hcatin Conlin Return) OOther(explain under#21 Remarks) FROM To DRSLRPfIOV feed.kWaaw.rWtwk sr.
C) R 3 R #__
o4.Date Well(s)Completed:�. Well ID# '1 n' t��(j n' OleSa.Wen Location: d R /G Rt,n
6 : �lll
FaciUrry/Ow" rer Nvre Facility ID4(aapplicable)
CIS 04dlnf h5 tl R R
PM1ysirFa��l Addru GIIY,and Zip
R n.
21.REMARK.S
County Puce)lkuificaunn No.(PIN) 1?e. Hor I f k a,L)
5b.Latitude and longitude In degreestmioutes/sernuds or decimal degrees:
(ifwdl rrdd.one IaUlong n Sufficient) 22.Certification: �� �/�
3- �-a l
6.Is(are)the weU(s): C3lfermaeat or OTemporary Sihnuare of Calified Weil C r Date
--11 6y signingtA6Jgm.I ken*cerro tW de ovens)ant(sere)conrtanewd u accordance uid
V 7.Is this a repair to an existing well: rrs or GNo /SA NCAC 02C.0100 oe 15A NCAC 02C.0200 Well Construed.,Sraadardr and that a copy
lfthu u a repair.Jill trot btonn wll coturrocuon infuranoun.and explain the mature f the ftkir reeoed Aar been provided to the cell on we
repair under a21 remade section or an the hack ofthis form.
23.Site diagram or additional well details:
S.For Gcoprebe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction.only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled. 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: .)G Ll fL) Submit this GW-1 within 30 days of well completion per the following:
Fw multiple ae/ls lip all depth ifdgnent(uample-7Qa 2lNI'and 2@10(f)
24a. For All Wells: Original form to Division of Water Resources (DWR),
If Static water level below[op of using: V (fL) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
II weer level it above casin g ate"-I"-
11.Borehole diameter: v (in.) 24b,For Injection Wells:Copy to DWR, Underground Injection Control(IUC)
t� 1 Program, 1636 MSC.Raleigh,NC 27699-1636
12.Well construction method: I\c T d P Tf 24c For Water SupoN and Oven-Loop Geothermal Return Wells:Copy to the
(ix.auger,usury,cable,direct push etc.) county.) I county enwronenta es department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR.CCPCUA
y�/ Pe rout Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) i� Method of test: /JC le✓
13b.Disinfectloo type:_AJIA Amauut:
Farm G W-I Noah C.I.Department of Emnoun ental Omlay-Mun.n of Water Resourco Revised 6 2019