GW1-2021-05468_Well Construction - GW1_20210722

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NSTRUCTION RECORD Ir For Internal Use only
ell Contractor Information:
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
as Q ft. 5-`63 q
it, ft.
NC Well Contractor Certification Number
` ( A / 15.OUTER CASING for mal -cased wells OR LINER f lieable
/—r�d� ®�O{ VJ ell
y / e. FROM TO DIAMETER TMCI�iEB$ MATERIAL
�ny Y�p, ` 111 �[i i `,l'J � iY. ft. !a. v 1L
Company Name
G D^ �I1`]I 16.INNER CASINO OR TUBING(geothermal closed Loa
2.Well Construction Permit#: r •�• J O"1 1 y FROM I TO DIAMETER I TRICKNESS I MATERIAL.
List all applicable well construction permits(1.e.WC,County,State,Variance,etc.) it. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural unicipal/Public ft. ft. in•j
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared)
1B:GROUT
irrigation FROM TO MATERIAL EMPLACEMENT ODdiAMOUNT
Non-Water Supply Well: ft. d ft. 1 �'a y I
Monitoring Recovery ft. &
Injection Well:
Aquifer Recharge Groundwater Remediation f t
19.SAND/GRAVEL PACK Iitiable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test C)Stormwater Drainage & it•
Experimental Technology Subsidence Control ft. it.
Geothermal(Closed Loop) Tracer 0.DRILLING LOG`attach additional sheete ff necessary)
Geothermal (Heating/Cooling Return) -Other(explain under#21 Remarks FROM TO DESCRTMONcolor hardnem soiltroek typik aralo dre.etc.
o ft• a n•
4.Date Welt(s)Completed: G�� •11 Well ID# fi aO ft. G(q
5a.Well Location: A 0 ft, A 0 C ft- ('Q h 1 t 6 k
� ft. ft.
Dee.* Cuerr
Facility/Owner Name Facility ID#(ifapplicable) ft. ft
11011 64 rit ri [6, rd 6 m ft. ft. ps
Physical Address,City,and Zip ft. it. 421
r
O L.r �Q.W1 2L REMARKS
County Parcel identification No.(PIN) SIII Unit
�fi C1(
Sb.Latitude and longitude In degrees/minutes/seconds or decimal degrees: u t 0f1
(if well field,one lat/tong is sufficient) 22.Ce on: --
N W
6.Is(are)the wells) Permanent or Temporary argon of Certified Well Date
signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or U(No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 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
i
9.Total well depth below land surface: O (�) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi ereru(example-3@200'and 2@1001 Construction to the following:
10.Static water level below top of casing: Z tS (ft.) Division of Water Resources,Informatlon Processing Unit,
Ifwater level is above casing,use"+^ 1617 Mail Service Cei ter,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Welts: In addition to sending the form to the address in 24a
above,also submit one copy of this`farm within 30 days of completion of well
12.Well construction method: f 0 �1 construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: l f 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) S Method of teat: -b `0 24c.For Water Supply&inlecti Wells: In addition to sending the form to
)� the address(es) above, also submit)one copy of this form within 30 days of
13b.Disinfectlon type:_ '` Amount: ` 16. completion of well construction to the county health department of the county
where constructed.
Form t3W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22 2016