GW1-2021-03057_Well Construction - GW1_20210624

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
I bj&l 14.WATER ZONES
FROM TO I DESCRIPTION
Well Contractor NameI,. Ab/A0*-j
Ybe/3- Cl ri.
NCWellContrietoi T, Urill I
IS.OUTER CASING for wells OR Lf (if
ap�li ble)
FROM 10 cased
D�pjp' 1 THIZN-KN*E9S- ATERIAL
:�--T—o
111c ft. I ft. 'in.
Cmnpziriy Name 16.INNER CASING ORT(.±!�. G�eothermal closed-loop)
iy TO r pJ.'_ THICKNESS MATERIAL
2.Well Construction Pcrmit#: 9C)AI FROM ,..I ER
3.Well Use(cliech' well use): ft. f. in.
17.SCRVEN
Water Supply NN el):
Water
FROM I To I DIAMETER IISLOTSJZE I THICKNESS MATERIAL
Agricultural n"icipaii-pubiii, ft. ft. in.
[Geotherm at(I ic-aling Coolin2 Supplv) Residential Water Supply(single) f, in.
I
IndU9triaIJCon-:*n�!.,, U; nResidential Water Supplv(shared) 18.GROt T
Irrigation FROM I TO — MATER% EMPLACEMENT METHOD&AMOUNT I
Non-""a W ter Supply Well: (3 f'. 1
C2415 f.
Monitoring Recovery ft ft.
Injection Well:
:)Aquifer Recha;_<' nGroundwater Remediation
119.SANI)!C.RAVFL PACYLfatipliciable)
:)Aquifer Storauv and RlecovcrN' nSahnity Barrier FROM TO MATERIAL ENIPLACE.\JENTMETHOD
:jAclud'er Test nstorm%,ater Drainage ft.
Experimental .,,;:nnoioa [3Subsidence Control ft.
Cie ffiermal t.Oop) [3Tracer
G 20.DRILLING LOG(attach additional sheets ifnecessary)
I ESCRIPTION(color.hnniness.soil/rock tyV,2min size,etc*I
Geothermal FROM I TO
Lip, z RCIUMIJ [30tber(explain under#21 Remarks 1 Clad
4.Date Well(s)(omoleted: Well ID# i 6
5a.Well Locati..1:
1>bU61f K oL-A L L.C.
ft.
Facilk\,Owner Vi J Facility 11)4(il'applicable) ft.
ft.
r aye- 11 7-46
\ddress.01'.;md Zip PInsical,
21.REMARKS
County Parcel Identification No.(PIN)
ib.Latitude and ion.-itude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one is loc,,u i-sufflicivia) 71
35* 211" 30- 10UP-P x 12*.a Lot 41? .5
"Oe�
6.Ware)the weil(s) ermanew or [3Ttmporao, 6'i,1111111(TC co'Conified Well Contractor Date
Bvsignii,,�,thi,fi,nn.I hereh.1 ce,nfy that the we/16)thus hiv in accordance
ontsinxied accordance
7.Is this a repa%-to nq existing well: E31!es or JEJ��o with ar IiA NVAC112C 0200!Pell Conviruction Standurds andthal a
!(this m a,-elhur. wel/a on,v nrtrun Infi,rintal"n und explaur lilt'11,11tire"f1he tr"ti'll"I//I",J.,rord hu.,been rrm-tded it,the ii-ellmiper.
repair under 21 r, on tfo,-hark ql thisfiwin. 23.Site diagram or additional well details:
8.For Geoprobe.:DP-f or Closed-Loop Geothermal Wells having the same You ma\ ase the back of this page to provide additional well site details or well
construction.oni, ! Cv,-I is needed. Inclicate'I"OTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:, SUBMITTAL INSTRUCTIONS
9,Total well depth below land surface: 1& 9,
A) 24a. For All Wells: Submit thisitbrm within 30 days of completion of well
Formulliple melt, i
:onstrUCI;0n to the l'ollowing:
10.Static water',-0 helow topofcHsing: Division of Water Resources.Information Processing Unit,
ffvaterk,elisah, 1. 1617 Mail Service C�ntcr.Raleigh,NC 27699-1617
11.Borehole clianie!-r: (in.) 24b. For injection Wells: In aldition, to sending the form to the address in 24a
above. also submit one copy ofthis tbrrn tvithin 30 days of completion of well
12.Well constrU,JGh Method: "Iflstrucil:,'!l to the following:
(i.e.auger.rotary. -iii-ct push.et,:
Division of Water Resources,Underground Injection Control Program,
FOR WATER S, PH,% WELLS ONLY: 1636 Mail Service C6t:er,Raleigh,NC 27699-1636
13a.Yield(glam) 12 Method of test. C&)JhX;W*t 24c. For Water Sunplv& Iniecti n I Wellsi In addition to sending the form to
the addret-sics) above. also SUbmit one coot/ of this fonn Within 30 days of
13b.Disinfectio--a Amount: � completion of well construction td the COUMV health department of the county
%%here constructed.
Finn G I North Carolina Depannient of Em immitemal Quality-onmon ofl------1 Revised 2-22-2016