GW1-2021-00594_Well Construction - GW1_20210205

Prim Face
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.—Well Contractor Information:
-Tarn Son rj1,I .-oY\ Ia WATER ZONES
Well Convector N. FROM TO DESCRIPTION
h' a3� ft.
p +�D II U, W
NC Well Convector Certifiotion Number 235 ft- 3LPb ft. 1O�
15.OUTER CASING(for multi-rued well OR LINER Ha
n PROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Companl NertR
1&INNER CASING OR TUBING thermal<saed-too
2.Well Construction Permit#: r7U I O a l I q(p 9 U FROM TO //D"-IAMETER THICKNESS MATERIAL
Usr dl applicMlr well cunsrruninn permit.li.e.G'1C.Cumu,,Sm+e.1'arience.erci Q n• 1 1 5 tt. W �ZS in. fF S+e e-
1
3.Well Use(check well use): tt. ft.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTEIZE THICKNESS MATERIAL
Agncultural ❑Municipal/Pubhc ft. h. in.
Geothermal(Heating/Cooling Supply) ❑R dential Water Supply(single) in.
Industrial/Commercial esidential Water Supply(shared) IS GROUT
bri lion mom TO MATERIAL EMPLACEAI ENTNETIIOD&AMOITT
Non-Water Supply Well: V n• 20 n- 37u'1�}f_ 00
Monitoring 11ecovery ft. ft. Ch,
Iltjectlo0 Well:
ft. ft.
Aquifer Recharge ❑Groundwater Remediatioo 19.SAND/GRAVEL PACK(Ha
Aquifer Storage and Recovery ❑Salinity,Barrier FROM TO MATERIAL EMPLACEMENTMEfHOD
Aquifer Test ❑stonnwater Drainage h. ft.
Experimental Technology ❑Subsidence Control
Geothermal(Closed Loop) [ Tracer 20.DRILLING LOG(atsch additional eases B )
Geothermal(Heating/Cooling Return) rJOther(eslain under#21 Remarks) moat TO OESCRIPTON Ienbr.haidnew.sWPmsR la see.ne.i
6 n• IIS ft C(O /ovCy)711v
4.Data Wells)Completed: _ �. Z I Well ID#
Sa.Well Location: ft• ft.
PC- Veki1 Lkres, nC n. ft.
Facility,Owwr Name Facility 113- ifapphiablel ft. ft.
b T)0.c,wr1 L,�,,rlc-- ft. ft.
Physical Addmss.City,and Zip /} /� ft. ft.
�7lIa�,l i� DY(C� -I.`J�'®L FIO a 11.REMARKS
ARKS
Count, Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Of.,It field,one Iat/long is sufficient) 22 rr`cation: /
35° 18153.452&3C N 820Z31 sv- oanos W �/ z
6.Is(are)the weIhs) rmanent or ❑Temporary / S- mrc ofCert'6ed Well Contractor Date
/ Hi x,;nin,In,,fore..l herrhs.errf fiat the .ell(re vas!w'rrel cneuvuctrd m aarnrdaear
7.Is this a repair to an exisfin well: ❑Yes or WfVo wish /5A h'C AC 02C.0100 or I5A.NCAC 02C.02W Well Conaruclion Standardl and rhal a
If rho is a repair,fill our k,umn well cnnxvuelion i ftiromrion and erplai,r the m,rure of the crip�eq this record lu.i hee,n prnrided w the will owner.
repair under*21 renearks seatlon or on the husk of tlue iren.
23.Site diagram or additional well derails:
8.For Ceopr abe/DPT or Closed-Loop Geothermal Wells havIng the same You may use(he back of this page to provide additional well site details or well
construction.only 1 GW4 is needed Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled. - SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: f �� 11e�s' 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple list all drprh,ifdd rent faminple i?'fi I' Gr/ 0 LJ construction to the following.
10.Static water level below cep of casing: y (ft" Division of Water Resources,Information Processing Unit,
If rarer I<rrl i.s ab..casing.use " F r f; X 5 �621 1617 Mail Service Center,Raleigh,NC 27699.1617
11.Borehole diameter. (a a,S (in.) 1 .For Iniection Wells: In addition to sending the torn to the address in 24a
n I ) i�.nroSSlfl� above. also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following'.
0 e.auger muse.cable.direct push.etc
sion of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276".1636
13a.Yield(gpm) Method of test: A . Onilghr?2 24c.For Witter Supply & Initiation Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form Within 30 days of
13b.Disinfection type: v-F'�0('(C Amount: -7 "^�S completion of well construction (o the county health department of the county
where constructed.
Form G\l rt' C ._z:.. . . ... r. ..:<::.. :-ar A..- e- dnuG:C:-]t16