GW1-2021-03483_Well Construction - GW1_20210607

1.Well Con actor Information:
EDe,1Jrr �
1 50 V) '14.WATER ZONES
Well Contractor Name r1s.
OM TO DESCRIPTION
n. 160 ft j
ft. ft.
NC Well Contractor Certification Number OUTER CASING for meld-eased wells)OR LINER'if a livable
O c! FROM TO DIAMETER t THICKNESS MATERIAL.
L V�MD 0 ft. If q ft. o.
Company Name 16.INNER SING OR TUBING(geothermal closed400'
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. fl. In.
3.Well Use(check well use): ft. [t. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public tt. ft. In.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft n, in.
Industrial/Commercial ORcsidential Water Supply(shared) 18:GROUT
hTi ation FROM I TO MATE EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6 ft. 1,0 ft. rG V,
Monitoring EiRecovery ft. ft
Injection Well:
ft. ft.
Aquifer Recharge [3Groundwater Remediation
19.SAND/GRAVEL PACK a "itcable
Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage If. ft.
Experimental Technology Subsidence Control ft. &
Geothermal(Closed Loop) OTracer 20.BRILLING LOG tatta6 additlonal.theets if 11kesaa
Geothermal eatin Coolin Return) rjOther(explain under#21 Remarks FROM TO DESCRIPTION color hardnes solUrock rains etc
r ® ft. � � ♦� J Q I
4.Date Well ts)Completed: 7 —2'Well ID# ft' Q 0 ft. &
Sa.Well Location: VD ft. ZZa & - # OGr.
R cI AXE, 11 c, M ft. fl.
Facility/Owner Name Facility ID#(it applicable) ft. ft. f"
h � G ft. ft.
Physical Adc�ess,City and lip ft ft
21.-REMARKS
County parcel ldentification No.(PIIN) SSlfi utllt
It v� DWR je":'Ofl
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifivell field,one lat/long is sufficient) 22. a Hon:
N w
6.Is(are)the well(s)MPermanent or OTemporary C
of 1 trac Dateg this fo l hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or [(No with ISA NCAC 02C.0100 or/SA NCAC 02C.0200 Well Construction,Standards and that a
If this is a repair,fill out known well construction 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1 0 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (fW 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@100) construction to the following:
10.Static water level below top of casing: Z Q (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
r above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 1 fit&�� 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
13a.Yield(gpm) Method of test: 1`o\;j 24c.For Water Supply&InjectiEon Wells: In addition to sending the form to
t_ L the address(es) above, also submit:one copy of this form within 30 days of
13b.Disinfection type: ►`"1 Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
i