GW1-2021-00722_Well Construction - GW1_20210322

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
GAM 661y 14.WATER ZONFS
w• FROM I Yo DFICRDR10N
Well Contractor Notce
IVl,YVl_ ;�)464 n. ft.
NC Well Contractor Certification Number 15.OLfIER CASING(for multi-eased wells)OR LINER(ir a linable)
tt ,^, N`` t C c FROM TO DIAMETER TRICKNFSS MAITRRIAL
WI l�n �.0�� (__1zil�ll Y`l�l1 iYll^ r
Company Name �/ 16.INNER CASING OR TUBING 1 thermal desed4 )
2.Well Construction Permit#:WdC..7oL�Q C FROM TO DI.cwl Mal TRICKNFSS I NUTFRIAL
Lie all applicable cell cmut....aou pernits l i.e.UIC.Counrt.Sand.Variance.e1.) —At"-*
t. ft. is
3.Well Use(check well use): tt- h. in.
Water Supply Well: 17.SCREEN
}ROM TO DUhfE'1'ER SLOT SIZE TRR-ANPSS b1ATERWL
Agricultural Municip:lFPublic [t. ft, in.
Geothermal(Healing/Cooling Supply) Residential Water Supply(single) ft. h. in.
IndusfiaVCommercial DResidenfial Water Supply(shared) 18.GROUT
Intanitlon FROM T(1 \IATERUL ENIPLACE.SI.NT METHOD&AMOUNT
Non-Water Supply Well: h. r It.
Monitoring EIRecovery ft. It.
Injection Well:
n. n.
Aquifer Recharge QGroundwater Remedialinn
19.SANDIGRAVEL PACK R a icaM1lto
Aquifer Storage and Recovery Salinity Banter FROM TD SuIEBLLL E\IPLACE6IENT METDOD
Aquifer Test QS[orr water Drainage
Experimental Technology Subsidence Control n. I ft.
Gemhermal(Closed Loop) ©Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DFSCRJP1mN 4mkc MWiaeie,satV k t. w,R0
Geothermal(Healing/Cooling Return) Other(explain
(under#221 Remarks) ft i ft.4.Date Wells)Completed: 5'<� Wen SDgVV2W Q�U ' n. t n•
Sa.Well Location: la n. 15
tt.
�e M �� G�► , n. n.
Facility Owner Name Facility ID#(if applicable) h. R. Q
VAlb, ft.
06
PPhhivvssiicaall Address,
Ca-V..on Zip n. It. p`
L.I IC.1zL)� I l-l..— 1,.� a Q 2L REMARKS r '
Coumv 1Pumel Identification No.(PIN)
5h.Latitude and longitude in degrees(minutes/seconds or decimal degrees:
(if well field.are lot long is sufficient) 22.Certification: i�
CQ
6.lattice)the wells) Permanent or Temporary Si nmare of Cenified W01 Conuactor Date
TN B signing this faun.1 hrrrb,reraft that the celho rear orere)constructrd in nC ordnnre
7.IS this a repair to an existing well: Yes or No r rh GA NCAC 02C.0100 or 15A NCAC 02C.0200 wcdl Gn...trmrlon St rdanl,and door a
If ibis is n nioun,ffl our known cell construction infiumrro nn m irpInin tlm nonne of tl ')P of this record Ims been provided to the nett tinned.
rpoir raider=21 remark, n imi ar,our it,back r f ohh fora
23.Site diagram or additional well details:
N.For GeoprobefDPT 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: t SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: W (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
Fornmhiple sells lin all drprhs ifdi/ferem fivanple-3ln200 and 2(d.Inn') construction to the following:
10.Static water level below top of casing: (D.) Division of Water Resources,Information Processing Unit,
ff nnrrr(reel i.nbnre rod+rg.use 1617 blab Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) .y`,.,s 24b.For Iniection Wells: In addition to sending the fort to the address in 24a
12.Well rnns[ruction method: I'Y 1 IZ 1 I v L 1`-F�� above. also submit one copy of this form within 30 days of completion of well
construction to the following:
lice:roger.rmarc.cable.direct push.etc) `
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: A I z 24c.For Water Supply & Iniection Wells: In addition to sending the form to
`1 '.` the address(es) above. also submit one copy of this form within 30 days of
13b.Disinfection type:hTY, �P.11CTJ Amour[: c�J(� completion of well construction to the county health department of the county
where constructed.
Form GW-1 Noah Carolina Depenment of Enviromtenml Quality Division of Water Resources Rerisad 2-22-2016