GW1-2021-03221_Well Construction - GW1_20210624

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: j
14.WAFER?ONES
Well Contractor Name FROM TO DESCRIPTION
q /l ft 13 2
2O L,
NC Well Contractor Certification Number U N ft. ft
/"�� J� p�r0 SSIf1f3Ulf :15.:OUTERCASING for'multi=casedivells OR-LINER'(if a 'licable
FROM TO DIAMETERI THICKNESS MATERIAL
!J��42 1�..��,�'Lif111 O ft. �2 ft. in.
Company Name
16.INNER CASING OR TUBING"`eothermal closed loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) fL ft. in.
3.Well Use(check well use): ft. ft. in.
Wa Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL,
Agricultural E)Municipal/Public '1Z ft. 13 2 fL (��' in. b sal" pile-
Geothermal
(Heating/Cooling Supply) Residential Water Supply(single) fL ft
in
mmercial IndustriaUCo Residential Water Supply(shared)
1 8.'GRGUT
DI
_s 1rri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q % 0 ft P6jf�� ft•,D l�at T
Monitoring ORecovery ft. ft.
Injection Well:
ft. ft
J Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK rf a"licable
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. fc
Experimental Technology 13Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer ,'20.-DRILLING16G attacti additional sheets if fiecese;a'•
Geothermal eating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardn soulmk type,grain size eta
4.Date Well(s)Completed: 6 J6 2 Well ID# g— ft. 3 ft. ; S f+,; Iva
5a.Well Location: r ft- (, ft- i s �c sv C/
Rorr,� A-hq /tor z.,le EC IL Fo ft. C G�
Facility/Owner Name Facility ID#(if applicable) 46 ft.
I b O ft. ge . ` _J 5' ref,,
32A< 6 Ck!_1.41 PJOC kwdo,4 P.C. 2930 100 ft' `y0 fL -0J ISF
Physical Address,City,and Zip
ft. ft.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i
(ifwell field,one lat/long is sufficient) 22.Certification:
3y° 36, 0 5- 7 /0* �� s' W ��
6.Is(are)the well(s) Permanent or Temporary Signature of Ce fled Well Contractor Dar
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: ..[]Yes or _ No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out knounr well construction:information and explain the mature 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.
filled' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /3 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following: I
i
10.Static water level below top of casing: / (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
H
11.Borehole diameter: 8 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
1(
above,also submit one copy of this form within 30 days of completion of well
12. n Well construction method: I�O 444 7 A-u ! I
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) ;
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: L 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) o Method of test: ��r 24c.For Water Supply&Infect on'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 typeM-ft Amount: Tow g completion of well construction to the county health department of the county
I '