GW1-2021-03154_Well Construction - GW1_20210625

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WELL CONSTRUCTION RECO G .
For .Internal Use Only:
1.Well Contractor Information: Ij 1 !
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L4 1� WATZI ZONES 1 I
Wdi Co Nsttte �� 6 ' FROM TO DFACRIMOly
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NC Well CounselorCatificanon' Numher
2S.OUTER CASIMG or mottirased aelb OR lam to
c c FROM TO D1AMEM Tmcra w MATERIAr.
CompanyName fL t B. In.
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id.INNERCA IDIGORTt7BIl�TG thermal ao
2.Well Construction Permit:.:bQ" t 0 D I FROM TO a]AMEM I IMC[QNM I MATERIAL
Llstatiappiteabkweftranrdrtctionpermits(Le.via Caun%Smt,rouneeetc.) It. ft. hL
3.Well Use(check well on): ft. M la.
Water Supply well: 17.SCRRW
FROM TO DtAMtSfER SL rs= IMCKN M$ tMATERW.
LZwthw=mWaII(HestWr/Coolmg
DMunicipaltPublic g,
Supply) ResidentialWaterSupply(single) ft.ommercial Residential Water Supply(shared) 1a.GROUT
FROM TO 7ERIAI. ENH A METHOD tit AMOUNT
on- eter Supply Well:
Recovery, ft. M
injection Well:
fir. it.
uifer Recharge 130roundwatcr Remediatlon
fer Storage and Recovery 19.SALVD/GRAVEL PACK if a eable
A" overy 13SalinityBarrier Mord TO MATERIAL EMPLACEl11BNTMETHOD
Aquifer Test 13Stormwater Drainage D•
Experimental Technology [3Subsideace Contml tut. R
Geothermal(Closed Loop) E3T=er 20.DREU MGLOG attach addltlonai sheets if a
lowthellual !afro Coo' Return) Othcr lain under#21 Remarks FROM TO DEBOUMO eotor sdU wk' eto
4.Date Well(s)Completed: —OV—4;L1 well lD#Ql V- `IQ f 01
4 Well Loc4don: i ft. R' ;
G S)n �-raaLl Kai. h ft. ft.
Faci ty/OwaarNama Facility ID#(lfapplicable) M ft.
.MVe im�1I � ':��t'�1le . mC,ajgO ftE .
Physical Address,City.and Zip ttr, ft
--.--— (046 .rye 21.REMARKS
County Parcel MentlfxcadanNo.(P"
5b.Latitude and longitude in degreeafminutes/seconds or decimal degrees:
(if well Sell,an IaMong is sufficient) 22.Certification:
r
x W a T424
6.h(are)the wali(s Permanent or Temporary Sl taco afCera' Well Contractor Date
lTTTT���� By this jaim l hereby oeri#fy that the w sTtlsl macs twsra)constructed to accordance
7.Ia this a repair to an existing well: ©Yes or wit 15A NCAC 02C.0100'or 15A MAC 02C.0200 Well Constructlon Standards and that a
ythk is a repair.fittoutknown MR canterucdon irtformatlo Loin the nature ofthe co 41�k record has bergprovidedta the wr/l owxer.
repa&under#21 remarkssecdon or on the backofftform.
23.Site diagram or additional well details:
L For Geoprobe/DPT or Closed-Loop Geothermal wells having the some You may use the back of this page to provide additional well site details or well
construction.only 1 GW I is needed. indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: , . ( SUBIt+fiTTAL R STRU TIONS
9.Total well depth below land surface: 11010 (ft) 24a.Far All Wells: Submit this farm within 30 days of completion of well
For muldpte weihr Oat andep#u i•fdii erent(m mpl-3@200'and 2@1003 construction to the following:
't
10.Static water level below top of casing: CM)+ (M) Division of Water Resources,Information Processing Unit,
Onter level ls above casing,use"+" 16111 Mall Servlce Center,Raleigh,NC 27699-1617
11.Borehole diameter: �,Q Crn•) 24b.Far iniectlon Wells: in addition to!sending the form to the address in 24a
t -? above,also submit one copy of this form within 30 days of completion of well
IL Well construction method: ^,,, construction to the following:
(i.e.anger,rotary,aab*direct push,etc.)
Division of Water Resources,Underground b4cetion Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Servlce`1
Center,Raleigh,NC 27699-1636
139.Yield(Sum) 20 Method of test: z 24c.For Water Suanly A Inildion Wells: in addition to sending the form to
the address(es) above, also subinii one copy of this form within 30 days of
` to,the county health department of the county
13b.Disinfection type.W)P��� completion of well construction Amount: ;
where constructed. I
i .
pwm GWI North Cuoltua Department ofEaviroaunental Quality-Division of Water Resources Revised 222 2016
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