GW1-2021-03524_Well Construction - GW1_20210607

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contractor Information:
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[ r•C cJ �e1 V 14.WATER ZONES
Well.ContractorNamc- FROM TO DESCRIPTION
fC y tL
ft. IL
NC Well Contractor C 5cation Number 'A' [ 15.OUTER CASING for multi cased wens.OR LINER'if a licable
"l1� �7 5 O✓t �j "V e t' f t,'I G' FROM ft. TO ft.
DIAMETER in. THICKNESS
MATE1ttAL
Company Name
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3 o 16 INNER CASING OR TIIBING(geothermal clo ed-loop' .
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.WC,County,State,Variance,etc) ft. It. in.
3.Well Use(check well use): It. ft. in.
Water Supply Well: 17.'SCREEN
FROM TO DIAr4ETER SLOT SIZE THICKNESS MATERIAL
Agricultural B?.sidential
Ipal/Public 0 ft �5 ft. in. Z L Lip P�jG
Geothermal(Heating/Cooling Supply) Water Supply(single) tt N in.
Industrial/Commercial EIResidential Water Supply(shared) 18.GROUT
lrri ation FROM TO MATERIAL LACEM" METHOD&AMOUNT
Non-Water Supply Well: it. 20 % .5 C�..A- B�/ 6C v) /
Monitoring Recovery ft. ft.
Injection Well:
ft. tL
Aquifer Recharge E)Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft. 1
Experimental Technology Subsidence Control ft. ft.
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Geothermal(Closed Loop) Tracer 20 DRILLING LOG'attach additional sheets'if uecessa `"
FROM TO DESCRIPTION color,hardness,solUrock" size,etc.
Geothermal(Heating/Cooling Return) _.�Other(explain under#21 Rematics) /h� �
V ft ® ft
4.Date Well(s)Completed:©cS Z� Well ID# O ft. Z O ft. tJ S ,( C h -(- �a•.t r
Sa Well Location: zC ft. 30 ft. C � c >~ t^�a
(y C hAw'15 . 6 reoL &f s �U tt tie ft `t
Facility/Owner Name r 1 acility rD#(lifpappliccaablee) �v fL ft �h,1
�a.a►�r,V A-�0 ✓�� Fe
it. ft. v
Physical Address,City,and Zip Q ft. R
21.REMARKS
County Parcel Identification No..(PIN) .
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 2021
(ifwell field,one lavlong is sufficient) 22.Certification:
3Y"9.o S$t N 01,2 SZ♦ W g..,n processing Unit
WR SSCVOn
6.Is(are)the well(s) -.. ermanent or Temporary Signature of Certi e-d Well Contractor 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 o with I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well co6truction 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-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 below land surface: / (f0 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:
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10.Static water level below top of casing: / ! (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 4, 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: m.
(� ) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: fW r' y t� 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: 1636 Mail Service`Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) Method of test: l qp _ 24c.For Water Supply&Iniection 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: 11� Amount: 01JJ4ay_ completion of well construction to(the county health department of the county
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