GW1-2021-00839_Well Construction - GW1_20210322

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well
Contractor
�Information: ` '\
i 14.IVA ZONES
Well Contractor Narne FBOM TO DESCRUMON
n. R.
N CW f 4---A3 n. n.
NC Well Contractor Certification Number rram�,, 15.OUTER CASING(for multi-used wells)OR LIVER fif le)
a 'TrC FROM Tn DIAAIEfER TRICKNESs 3L1T11tI.11.
Cooparry Name -f/ 16.INNER CASING OR TUBING 1 dined-1 )
2.Well Construction Permit#: _ C2(3 / Frronr ro -NIA .
List al/app/icnb/e a e(I rmismatinn pemdrs li.e.UiC.Cnnnn'.Stine.Yarimme.err.! R. /L in
3.Well Use(check well use): rt. R. in.
Water Supply Well: r.SCREEN
FROM TO DIAh1ETER SLOTSITF TaICI[NM MATERIAL
Agricultural MurticipaVPublic R. R. in
Geothermal(Heating/Cooling Supply) Reciden[ial Water Supply(single) Ft
. R in
Ind mn ustrial/Cotemial QResidenfial Water Supply(shared) Ill GROUT
Irrigation FROM To I NIATERIA/. E IT ACt'MENT MErROD&ANIOUNT
Non-Water Supply,Well: n. 1 ❑. Q - -BycpS
Monitoring Recovery
Injection Well:
FL It-
Aquifer Recharge QGmundsvater Remediation 19.SAND/GRAVEL PACK(H hk)
Aquifer Storage and Recovery Salinity Battier FRmt 7o sIATEwat EMPLACEI1ENT stETitoD
Aquifer Test QStonnwater Drainage
Experimental Technology DSubsidence Control
Cothermal(Closed Imp) QTmcer 20 DRILLING LOG launch additional sheets if )
Geothermal(HeatingiCoolino Return) Other(explain under#21 Remarks) ]FROM m DESCRVI'IQN(cebr.h.rd.m mvr.rt. ,;s eser
R 1 2
4.Date Well(s)Completed- -)U -,x 1 wen ID#j )3,33 -L V rl n. I rt. 5
5a.Well Location: IL Deco IA 0 5pa Z
N1} PA l Cc X n. "
FecililwOwner Name Facility ID#(ifapplic bk) R- R.
Iq CGX L-n , NC �3W14 N1 FL
Physical Address.City.and Zip R. R.
tSiJ��L.-�-' 14gc:�) 21.REMARKS
Cwmr P..I Idemft u..No.(PIN)
5b.Latitude and longitude in degrees/minutes/secoods or decimal degrees:
(if,sell field one belong is su(ficien0 22.Certification:
}mil, N W ( UA--Q.0
6.Ware)the w•ell(s)311Permauent or QTemporary Si ore of Certified Well Contractor Dale
s ning this fomn l herehr cerfifi'Char the nell(s)ens Prere,rocnmrted m accord
7.Is this a repair to an existing well: QYes or No nirh 1 iA NCAC 02C.0100 or 15A NCAC MC.0200!Yell C..,n,ctim,St..,i.nlrtand thin n
If this is o re/ain fill out bman,re/I mrmnrainn it f....ntim(mrr}r_q loin the nntore he '*9Cy f rhk record has been provided a the net/ouner.
relwiramder#21 remarks section or an the bark of rbis jooa.
23.Site diagram or additional well details:
8.For GeoprobelDPT 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 shells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
�r�t
9.Total welldepth below land surface:� lY (fL) Zqy For All Wens: Submit this form within 30 days of completion of well
Fnrnmltiple velh Bsn ail depths ifdi$erent lemmple-30.200'sad 2 rCdlon')
construction to the following:
10.Static water level below top of rasing: (XJ UL) Division of Water Resources•Information Processing Unit,
/framer lore/is abare rasing.toe +- 1617 Mail Service Center,Raleigh NC 276"-1617
11.Borehole diameter: (.1) (in.) ` 24b.For Iniecton Wells: In addition to sending the form to the address in 24a
A ` J ' R l above. also submit one copy of Ibis form within 30 days of completion of well
12.Well construction method: A !^ U 1 1`t construction to the following:
(i,c.sue¢mtarv,cable,direct pmh.cic.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276"-1636
13a.Yield(gpm) , Method of test: 1 IZ 24c.For Water Supply&Iniection Wells: In addition to sending the fomr to
gypp� the address(es) above, also submit one ropy of ibis form within 30 days of
13b.Disinfection type: 1 �- Amount: NJ completion of well construction to the county health department of the county
where constructed.
Farm GW-1 NoM Carolina Depaamem of Envimnrmnml Qmlity-Division of Water Resoumes Rceiscd?'_='_01 fi