GW1-2021-05847_Well Construction - GW1_20210709

Pjnt Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1 ell Contractor formation:
o s�� ,.EC��\l�
1a.WATER zoNEs
Well Contractor Name FROM TO DESCRIPTION
JULIlk
0 `� 2021 fL fL w
Unit ft. ft.
N �We1lContradorCertiUK"
be jnfQlmat0nproCeSS►n9 15.O ER CASING forTulfl-dwdwells ORLMR da "'able
1� OW �� �WR SECtI0T1 FROM TO DIAMETER THICKNESS MATERIAL
ft ft in.
Company Name
I&INNER CASING OR 1YIBING`(geothermal dosed-1
2.Well Construction Permit#: FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(I.e.UIC,County,State,Variance,etc.) k !j ft. 1'J9 fL in. L►\ 1 LO D 1 `/
1
3.Well Use(check well use): It. fL in. C1-f ` V
Water Supply Well: 17.SCREEN.. `'
FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
LGeothermal
ricultural [3Municipal/Public MOIL t).C7� ,n, 0 O G
(Heating/Cooling Supply) g]Residential Water Su I sm e ,` 5 ��Vo..J PP Y(� gl ) fL iL io.
ustrial(Commercial Residential Water Supply(shared)
1&GRO[Tf
Ration FROM TO MATERIAL EMP CEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft. (�ft. At-6l_ A_0-tk-0,-_ -
---- -
`----- Monitoring- -"� Recovery ft. fL
Injection Well:
fL n
Aquifer Recharge 13Groundwater Remediation
19.SAND/GRAVEL PACK N anollic6hlel
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATFJUAL EMP CEMENT METHOD
Aquifer Test ElStormwater Drainage Cl qft' 2<)fL S) I t (h
Experimental Technology 13Subsidence Control fL R
Geothermal(Closed Loop) ElTracer 20.1)RII LING LOG athch additional aheetsidn
Geothermal(H ofing Return) 00ther(explain under#21 Remarks) FROM It. if.TO DESCRIPTION(color,hardn=4 soiltrock eta
4.Date Well(s)Completed: Well ID# fL It,
58.W++ 11 Location:
fL
�l l�1 A Van C' "fl ft. fL
Facility/Owner Name f� F ility ID#(if applicable) ft fL
mg ,"`\\\ •7 AcS�� r� � ft. ft.
Physical Ad s,City and Zip ft. ft
Uvt�\ � '21:REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) iCertificatio f
3I .2ct 21 N -I(o°, 03 .Os! I w �
6.Is(are)the we0(s)jRfermanent or Temporary SignatabofCcrtified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or [DRo with ISA NCAC 02C.0100 or I5A NCAC 02C.0100 Well Construction Standards and that a
Ifthis 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 I GW-1 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: ` hu (R) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2 100�" construction to the following:
10.Static water level below to (,�
P of casing: � / (fr•) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing:use '+
r 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: r (in.) 24b.For Infection 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: n k construction to the following.
(Le.auger,rotary,cable,direct push,etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Infecti f 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 type: Amount: completion of well construction to the county,health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Watcr Resources Revised 2-22_2016