GW1-2021-03069_Well Construction - GW1_20210624

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
—I-0sy),k's s 14.WATVR ZONES
Well Contractor Naoi,, aEEi_�To DESCRIPTION i
0 11. -3.2 0 ft.
40 Ct P, ft. ft.
NC Well Contractor CQi1ification Number 15.OUTER CASING(for multi-cased wells)OR LInER Iif gonlica le)
-FROM TO L DIAMETER! I THICKNESS 1 MATERIAL
Company Name
16.INNER CASING ORTURING(geother III closed-loop)
2.Well Construction Permit FROM i TO OIAMVITR THICKNESS I MATERIAL
ft. ft. . in. P. C_
­"truction pertivis ti.r,UIC.Cm um State. n) 0
ft, ft. I in.
3.Wall U well(check ell use): i
Supply NN ell: 17.SCREEN i
FROM TO DiAxIETER i SLOT SIZE THICKNESS MATERIAL
Agricultural M icipal/Public ft. ft. in.
ic-p
Geothermal I H"mna Coolina Supply) K,,,d,:n
Q esidential Water Supply(sin le) r. in.
IndustriallCor.-�nc�%:�il nResidentiai Water Supph-(shared) I&GROt:T
Imitation FROM I To MATERIAL I EMPLACEMENTNIETHOD&AMOUNT I
Non-Water Supply Well: ft.
12o
RecoNery ft
Monitoruni!
Injection Well:
ft. ft.
3Aquifer Recha;-.e ®Groundwater Remediation I
1 ll�l S\All�)!17,4V F L PACK(,.Lf Ipplicable)
DAquifer Storag,,jnd Recovery nSalinity Barrier 0 , To T MATERIAL. EMPLACEMENTmETHOD
-JAqufl-er Test [3storm%\ater Drainage ft. ft.
Expernnental':e,�,-nolo y nSubsidence Control ft.
Geothermal Loop} nTracer N'
20.DRILLING LOG('attach additional sheers,if necessary)
FROM 'TO DESCRIPTION(color.hardnem.soillrock typt, rain size,etc.1
Geothermal(11­-ilit-�L,'Cooling Return) tither(explain under#21 Remarks) I
I D ft. ft.
4.Date Well(s)(ompleted: Well ID# ft. ft.
Ila • 61115-
ft, ft.
5a.Well Locati,,w i
ft. ft.
(i. ft.
Facilit),Owner Mn Facilit\ 11),?(iftipplictible)
ft.
WAVI.-ViOA Dr. M60 A 1-1 U I
PhysicafAddress.Cii�.�md Zip ft. JUN 2 4 202i
11.REMIRKS lnfefr,gin Rro-rPssind
KC C�o Lo­�I
FAN
cll a,
e
County parcel Identification No.WINN, VVR S -doll
5b.Latitude anu tongitude in degrees/minutes/seconds or decimal degrees-.
(if well field,one 1:r lonu-is sufficienn
22.Certification:
3S6 L13, g3.,q13qSt1__ glo 61 , go. )3u kog
le (P ;P—
pianire ofCenificd Well Coniractor
6.Is(Are)the Nvell(s)elp"'cl-anent or Temporary" 1011, Dar
M.slgnn,�,1""),form,I hereh.1 cem wa.,A,vre,ows!rncfed in accoulance
,(%•thot the ii
7.is this a repa,-ta.in existing well: [31'es or ;V. wall 15.4 A(ACO2(L.11JJ)J1(,r
if ihis r,,a terror,r.-own we//um(ruction Me mutirt-4 the ,"pT w 11u,/.'VON/hu,,hevn proi%led it,the ircilawwr.
repatrumler 23.Site diagram or additional dditional well details:
8.For Geoprobe DPT or Closed-Loop Geothermal Wells having the same You ma\ use the back of this page to provide additional well site details or well
construction.on;, o,-I is needed. Indicate TOTAL.NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth beiow land surface:
214a, For All Wells: Submit this!form within 30 days of completion of well
Formiduple Construction to the following:
10.Static water'v­e'below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
i
1617 Mail Set-vice Center.Raleigh,'NC 27699-1617
11.Borehole diameter: (V (in.) 'ion to senclint,the form to the address in 24a
24h�For Iniection Wells: In aldiI , sending
above. aiso submit one copy of this tbrin Wiihin 30 days of completion of well
12.Well constrt,ritiii,method: �Ix construci:on to the folloxvinia:
(i.e.auger.rotas. j ccct push.etc
Division of Water Resources,11!nilergrotind Injection Control Program,
FOR WATERr�PHA WELLS ONLY: 1636 Mail Service Centi1er,Raleigh,NC 27699-1636
1 1
24c. For Water Sun o Wells- In addition to sending the form to
13a.field(gpm) Method of test: n1v& Iniecti n
the addrcs(es) above. also submit one cod} of this form Within 30 days of
13b.Disinfectio.i,vne:_C 10tNe. Amount: 3 4rA 1.6 completmi't of well construction to the county health department of the county
where constructed.
Forin CAV-I North Carolina Depainnient of Em,ironimmal Qteiln\-i)i\mon of 11ater Rcsnarceli Revised 2-22-2016