GW1-2021-01742_Well Construction - GW1_20210209

WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Onh:
1. it Contractor Infor ntatti�o/n�:
V�LI��N 14.WATER ZONES j
Well Contractor Name FROM TO DESCRiMON
z ft.
R
NC`Well Contractor Certification Nu her 15.OUTER CAS G for multi-eased wells OR LINER fifannfimh1el
FRO. TO DIAMETER I THiCKNESS I DATERIAL
Company Name
` . `�00-7O \ 16.INNER CASING OR TUBING eothermal dosed-loo l
2.Well Construction Permit#.. w FROM TO DIAMETER THICKNESS I MATeRtAL
List all applicable well conunterion permits ti.e.IW'.Cowin:Slate.tarimrce.etc.) k ft. 2q 0 IL in n \ f�\1 r.
3.Well Use(check well use): ft• ft. in. 1 ♦ v
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTS17.E THICK\ESS MtATERIAL
Agricultural �Municipa!/Public � ft. Q in.
Geothermal(Heating/Cooling Supply) DResidentia(Water Supply(single) ft ft. in.
__ IndustriaKommercial DResidential Water Supply(shared) 1s.GROUT Y
-11TTigation FROM TO MATERIAL EMPLACE:'1iENT ME MOD S AMOONT
Non-Water Supply Well: 0 ft. 0 ft. %S-00sq0t.
t.
Monitoring Recov ?d 2p�b
Injection Well: fL R. CGv+���k
Aquifer Recharge C]Groundivater Remediation ft. ft.
19.SAND/GRAVEL PACK if anblicablel
Aquifer Storage and Recovery OSalinity Barrier FROMi TO MIAT£RIAI. flIP1�ACEMiEAT METHOD
- Aquifer Test �Stormwater Drainage ft. ft.
E tperintental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) •Tracer 20.DRILLING LOG attach additional sheets ifnecessa
Geothermal(Heating/Cooling Return) Otfier(explain under#?1 Remarks) FR°nt TO DESCRIi W%(eolor.hardness.seit1rock t .Frain size,etc
ft. ft.
4.Date Well(s)Completed: \r).\Q V IoWell ID# ft• e
Sa.Well Location: ft. ft.
PSG"V- % A\h4 C-w►b T,wc.. 2 y0 ft. I 6 ft-
Facility/Owner Name Facility tDr(if applicable) ft. fL
N C..\kw\A 301A . *Nt.s�6 2$1-15 ft.
v .
P iral Address.Ciq.and Zip ft.
�.
?QN-IN Ce0 i VA\314'N�2 8 op 21.RER
County Parcel identification No.(PiN) B X
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,oneiaUlon s sufficient) r W"1
e F i®su ) ICP
22.Certifi�at�
IJoA� rb3Z7i \ 7 6 11 . y�©� 11' �`•'ytry `
6.Is(are)the well(s)oKermanent or DTemporary SiEma ure o ertified well Contractor Date
Bi•signing this farm,1 herehv cerh•that the uvllls)uav/Irene)constnicical in accardanve
7.Is this a repair to an existing well: Wes or 021,'%o with 15A X AC WC.0100'or!SA NCAC 02C.0200 11 c11 Cnnsinictiwt simnlanly mid that a
If this is a ropair,Jill out kimuvi trell con inicxion inftrotation mid explain the nature of'the cane of this rtcanl has been pnirided tofilig urli au•ner.
mpair wider-21 remart i-salion or tat the back of this form.
23.Site diagram or additionatwell 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 construction details. You may also attach additional pages if necessary.
drilled: SUBIl11TCAL INSTRUCTIONS
9.Total well depth below land surface: (D•) 24a. For All Wells: Submit this form within 30 days of completion of well
Far tanhtple irells list all depiltr ifdifficant(example-3,02110'and 2@1001 construction to the following: a++
10.Static water level below top of easing: $ A) Division of Water Resources,Information Processing Unit.
lfisnrer lered&above coring nxe--- 1617 iinil Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: L7 (in.) 24b.For Iitiection Wells: In addition to sending the form to the address in 24u
�� above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the followine:
(i.e.au6cr,rotary,cable,direct push,etc.) -
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: p 1636 Mail Service Center,Raleigh.NC 27699-1636
13a.Yield(gpm)ISO Q Method of test: ` VkV*Jz 24c.For Water Sunniv A Iniectioti Yells: 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: ` Amount: \aS completion of well construction to the county health department of the count'
where constructed.
-e.
Form GW-I North Carolina Denartment of Environmental Ouallty-nhisinn of\Nate'Recmmrx 0-.4-. 1»In,z