GW1-2021-00593_Well Construction - GW1_20210205

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use OnIN'.
I.%Tell Contractor Information:
JQm I.SO'r,, at`,/11 l' Sd(\ 14.H-.{TER ZONES
FROM TO DESCRIPTION
\\'ell C onrtagor Natal,
Z I o or �
173- ft. rt.
SC U'dl Conrtador('enification Wniher 15.01TER CASING for mulri-eased wills OR LINER ifa lieable
k[� FROM TO DIA{IErf:R MKIlNF.SN MATF.RIAI.
')r) se rvl1r o C lInc . ft. ft. ,n
Compam Name
1 // � 3 16.INNER CASING OR TUBING eothermal closed-too
2 Nell Construction Permit# �I�,l { Cjlfl9 FROM TO �^ UI{MEI'in THI('A\fse MATFRIAL
pph.rrnl, ,-rllroirvr,avr„ f iur r Cj n. JI J tc �i. Zd—in �6 S fttl
3.Well Cse(check well use): �
a. D.
7.SCREE[
Water Supply Well: FROM to DI{MfS4R SLOT SVE THICKNESN {IATf:R1AL
:{grrultur,tl �Mu mill Public ft. ft. m
Geothermal(I leatine/Coolinc Supplv esldenual AAater Supph (singlet ti ft in.
Industral/(ommercial Residential N ater Supplv ishared) 18.GROl'T
Irr£ation FROM to M%TERI:\L EMPLA('EMEN"f METHOD&AMOUNT
Non-Pater Supply Well: 0 fr' o(O t0' n1it U Lt.
✓ _
Monitoring Rrco,en
\
Injection Well:
ft. f1.
Aquifer Recharge DGround.,Her Remediation
19.SAND(GRAVEL P.ACR ifa lieable)
Aquifer Storage and Recocen �SaIImv, Barrier FROM TO NIATIOUM EMPLACEMENTMETHOD
:\gofer'lest OStormoater Drainage ft. ft.
E\penmental"lechnolog, �Suhvdence Control ft. H.
(izothermal(Closed Loop) Tracer 20.DRILLING LOG tench addidonal sheetl if neaessan)
FROM TO DES('RIPTION I.tar.M1a,Lnew.soif,akn ac.rta.
Geothernal(HeatingiCoohng Return) Otherteylum under 421 Remarks) O ft. Il �ft. CI0.
4.Date NNellls)Completed: 1- a .�- t Well ID# ft. ft. r
fi. ft.
Ja.Nell Location:
HC VinAk-t S .InC. ft. ft.
Pacdm OwnerNeum Fec lnc lD=of apphcahle) ft. ft.
(��Lod-�Io in. ft.
b )cx_".yn Lms, firtncUrsonv,Ile . NG as-19z
Phs1s,�,i %ddress-('itp.and Zip O /�-I'l I 11. f.
✓l G{f YS�t�I q5 d FV I40(, S 21.REM.\RKS
Conn Parcel Idenu tkaiinn Co.(illy,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
of,ell field,one laJlongissuticicni 1 22.1 er' Ication:
Sr. IcAT41 KZ52-3t `f5 . 123aU N
6. Is(are)the"IIb r1 ermanem or [3Temporan" ,nature a('mdifi d -c (.ntrvaor Date
rt. ::........11111/�+rra./hIlLbl 11111ft rl N ,r//nr n. r r / darrre
7.Is this a repair to an existing well: E]l'es or gltla� .�ah I lA V('21 ON 0100 ,r 1 i I V( ar a (' o?oo Hirt(' sworn....N'm standard,and Ihar o
1/rho I.I.rrp,ur.Gil au(knmur a ell.ornrraeoea m/nrrneu...em/,r,/... d..a..ure,d do aq,i.,u1u:soon/ha,hrea p,I.... d ro rl r.e11 o.,ncr.
ropm....Ar 'I"nwk..eemm„r,,,i drr 6J[k„l lbrr A,ro,
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells ha\mg the same }o ise the back of this page ,o provide additional well site details or well
construction,onh' I GP'-1 is needed Indicate IOI AI_Al A16LR of azll> n dz4tils You aim also attach additional pages ifnmzssan
drilled. �U k- SCRVll'I IAL INS]Rl('PIONS
y
9 total well depth below land surface: .3 C)S IfIJ (�iy� � .III Welk: Suhnut this fare within 30 days of completion of well
1- ../I,h.roll lmalldrprh,d tl,,rrru ..amyl ,?On'.rnJJ,I lnu7 �� js constmctty��di��followine:
10.Static water level below top of casing: d ((�.17(^'eson Division of N'aler Resources,Information Processing(nit.
Cje�l�n 1617 Ntail Sen'ice('enter,Raleigh,NC 27699-1617
11.Borehole diameter: G . 2 5— (in.) 24b. Fur Iniection Wells. In addition to sending the Corm to the address in 24a
��Q ohovc. also suhmu one cops of this lorm vvnhm 30 Jaye of completion of well
12.\1 ell construction method: construction to the lollm"nu
I e Migta ratan,cable.direct posh.etc
Dismon of N ater Resources,l nderground Injection Control Program,
FOR WATER Sl-PPLA'FELLS ON LA: 1636?Tail Service('enter,Raleigh,N('27699-1636
13a.',field(gpml Method of test: Q CoActi(ler 24c. For IN ater Suonk & Iniection Wells. In addition to sending the form to
the addmssl,) above. also sibinit one copy of this form vsithm 30 days of
13b.Disinfection type:C(V IO((ne Amount: 3 �17-(1 completion of"ell construction to the counh health department of the county
where constructed.
FormGM-1 Nonh Canrlma Depumnent of hall..... nmlQualo,-D..lsnm of Water Raourco Reused2-22-2016