GW1-2021-03242_Well Construction - GW1_20210628

WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
1.Well Contractor Information:
1wt RA 14.WATER`ZUNES
Well Contractor Name FROM TO DESCRIPTION
���� �� �� �� ft. 3.�1 ft.
666��� Q 2� ft. ft. I '
NC Well Contractor Certification Number
J`J� $ n unit l5.'OUTER CASING for multi-cased wells,OR LINER' if a licable
i e,&,b �llL� 501h, ,' p�O S�1C,y ^ ft 5 ft. DIAMETER in THICKNE MATERIAL
oI lt9 t/ .J 1 4Rw/L,
Company Name 1� R S
�^-�f-7 pp A D� ,16.INNER CASING OR TUBING" eothermalclosed=loo
2.Well Construction Permit#: 2- /'0 I-/r FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. fL in
3.Well Use(check well use): B' % In.
Water Supply Well: I SCREEN '
FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
Agricultural rcrpal/Public 3 3 ft- 3 V ft, in: l L
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. fa in.
Industrial/Commercial Residential Water Supply(shared)
A&'GR'OUT,, _n.
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
—XVNon-Water Supply Well: Q Zp { /�fx
Monitoring __Recovery ft. ft.
In Well:
ft. ft.
_ Aquifer Recharge Groundwater Remediation
19:SAND%GRAl'EL PACK d a' licable ., ., .';r X
_I Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [)Stormwater Drainage ft. It.
Experimental Technology Subsidence Control ft. ft. i
-i Geothermal(Closed Loop) Tracer '20.DRILLING LOG attach additioiia4sbcets if necessary)
Geothermal(Heating/Cooling Return) ;Other(explain under#21 Remarks) I
FROM TO DESCRIPTION colbr,hardness soil/rock type,grain size eta
d ft. 3 It. ria "Is,i I I Cf
4.Date Well(s)Completed: 2g�Z� Well ID# 3 fL ft
5a.Well Location: ft fr
2-0 IL
5¢fl fIG¢J3� ®AJ✓! �.�Jrt � 2� ft- ft
Facility/Owner Name Facility ID#(if applicable) 3 6 It- ,YS- f4 J G
Physical Address,City,and Zip ft. ft.
�i6�vn ate- p_,o29 :21.ItE11fARK5
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3y° 240 037 N 9 g /0- l/ W r
6.Is(are)the well(s)A;ermanent or Temporary Signature of Certified Well Contractor J Date
By signing this form.I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or __ No with 15A NCAC 02C.0100 or 15A NCAC 02C.0260 Well Construction Standards and that a
If this is a repair,fill out(mown well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
Q e
9.Total well depth below land surface: V (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resour jes,Information Processing Unit,
If water level is above casing,use"+"
,— 1617 Mail Service fen"ter,Raleigh,NC 27699-1617
�d
11.Borehole diameter: ] L (in.) 24b.For Infection Wells: In additi on to sending the form to the address in 24a
above, also submit one copy of is form within 30 days of completion of well
12.Well construction method:
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Gen Iter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: �f" /`+ F 24c.For Water SunDly&Iniect io n Wells: In addition to sending the form to
T the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: �fl �f Amount: tT W+,� completion of well construction to the county health department of the county
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