GW1-2021-01082_Well Construction - GW1_20210322

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor Information:
� 14.VVATRR7,oNES
Well Contractor Namc FRO)[ TO DESCRRT[ON
W-y C 42)63 It. R.
VC Well Contranmr Ccnifi``cmion Numh`cr 15.OUTER CASING(for multi-eased wells)OR LINER(if a Noble)
��I 1 U1 (AJ�,i, l 1\Z, i i ) V1 Q IN) C + MO`[ rL TO ff. DL4.VIE1'ER m TRICh-^IE55
Company Namc
1 / 16.INNER CASING OR TARING( eotbermal closedlam- )
2.Well Construction Permit#: 1 N.� � (](�)(; ) FROM m nL+aa-ts.R Tntclven vaTEruAL
Lim all.pplimblr umlt,tarn........p,c,,ira O.e.UIC.Caamv.San,.✓aria....ea'.I rt. D. in.
3.Well Use(check well use): It, n. in
Water Supply Well: IT SCREEN —�
FROM TO DMNM- ER SLOT STZE THiCE.N MATERIAL
Agricultural QNlunicipaL""Public n. n- �.
Geothermal(Heming/Cooling Supply) Residential Water Supply,(single) r6 fl in
Industrial/Commerciil Residential Water Supply(shared) I&GROUT
In-walion FROM TO JIATE U METHOD&AMOUNT
Non-Water Supply Well: O t ft. '1(�t n• _
Monitoring DRecovery ft. d ft. 1
Injection Well: —'-It. I R
Aquifer Recharge FIGrouncluvater Remediation
19.SAND/GRAVEL PACK tda ble)
Aquifer Storage and Recovery ®Salinity Barrier FROM TO SUTetWL _ EMPI-AIM ENTNIM10D
Aquifer Test ❑Stonmvater Drainage R. n.
Experimental Technology QSubsidence Control ft. I n.
Geothermal(Closed Loop) QTracer 20.DRILLING LOG(attach additional sheets Ifucewars)
FRo>t TO DFSCRIPT'taN 1<abr.hved,xcc sgiemran srrr)
Geothermal(HeatinJCooling Return) Other(explain under#21 Remarks)
1 ',,,^. ,, j1, C IL D.
z , NI'� fzn( TL i t ❑. 1 rl- L 1
4.Date Wells)Completed: .z�V� -•� Well ID# J � -7
Sa.Well Location: J ,f I fL rL Sr
n. ft.
FacdiilinaO,rrcr Name Facility ID:l if applfcaMe)
MI1 M ft. ft.
irz� i`�1)ar1�i r_ N c o,-
ehQ.,Address.Cox and Zip n. ft. ;
21.REMARKS
( �)�tea;ICe.iujri�� , t �
Couniv Pa¢d Identifiotion No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if'ell field.cox latilon_i"mficiew) 22.Certification:
6.Is(am)the well(sAlVermanenl or ®Temporary Si numre W enihed Well Contmaor Date
F(�t
B_+sgamg+hh foria. I hrrehr renib'+hal o"uellCq gnu h"'r rmurnvrrd in"""i.....
7.Is this a repair to an existing well: QYes or No \ h 15A NGIC 0_'C.OIW ar 15e1 NCAC 02C.02W IV.dt Cnnsrmoinn SmndnnLs mid Ilia,o
Ifild,i,n n7,.ir.fill gw bmr,n�,,l..n<err.nnn i,fa.ei...a. .rplom the...... if1hr ,,,r John,reonrd ha,been prnriderl m rbr nrll nonrr.
, pta.vnJer?2/renmrl,ae•ni.n or nn Jm ha.k r fgris fima
23.Site diagram or additional well details:
8.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 I GW-I is needed. Indicate TOTAL NUMBER of wells constmction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
i
9.Total well depth below land surface: Ql.) 24a. For All Wells: Submit this form within 30 days of completion of well
Far rn.blply sell:li,r.n depot,ifdii fcreni mrmrsplr-3C200'.nd 2C rum) -
comswction to the followeng:
tl
10.Static water level below top of casing: SU (ft.) Division of Water Resources,Information Processing Unit,
quarry level i..Mree<nving.+rse 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniecfron Wells: In addition m sending the form to the address in 23a
� above. also submit one copy of this form within 30 days of completion of well
12.Well (
construction method: 1}1 IZ I (AR IZl_: construction to the following
(i.e.aueer.meant cable.dimct push.etc.) --�
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY\HELLS ONLY: ,w 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 Method of test: 24c.For Water Smi&Infection Wells: In addition to sending the foot to
the address(es) above. also submit one copy of this form within 30 days of
13b.Disinfection type:, !��11p Amount:3(: completion of well construction to the county health department of the county
where constructed.
Foot Gw-I North Carolina Depanmcm of Fii,ronmeaul Qwlity-Dirisiun.1 Water Re,00cc, Revised 1 12-1_016