GW1-2021-00966_Well Construction - GW1_20210404

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: f
1.Well Contractor Information:
/11'I 1� TI 14.WATER ZONES.
FROM TO DESCREMON
Well Contracte Name
-3 S'4 I .5'oc
NC Well Contractor Certi'ficalItion Number 15 OUITR CASING for multi eased wells OR LIIVER da 6le
S' y t S W I I W '! I�I Ci FROM To 1 DIAM/ETE� 1�C�IE99 MATIItiAL
�'�' R A q r0 In. e 0�/D PJ C/
Company Name
_ I&B94M CASING OR TUBING thermal dosed-!oo
2.Well Construction Permit#: 3,i �p 5 FROM TO DIAMemt ITHtCKKM I MATERIAL
List aff applicable well construction permits r e.UIC,Conudy,State,Variance,eta) &- H. is
3.Well Use(check well use): D' m
Water SnPPlY Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE IMCN74M MATERIAL
DAgricuftttral OMunicipaUPublic U ft. tL in
Geothermal(Heahng/Cooling Supply) Residential Water supply(single) ft, n,
IndusttiaVCommercial DResideatial Water Supply(shared) M GROUT
ril-igation FROM 170 MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 & 3 & =LH
I. w d-
Monitoring O ar 3 ft- a D ft.
Q
Injection Well: !I. ft.
Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK da 'cable
er StorW and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEM@NT METHOD
Aquifer Test OStormwater Drainage ft. M
Sxpetimentai Technology OSubsidence Control ft.
Geothermal(Closed Loop) OTracer 2&DRILLMG LOG attach additional sheets itneeessa
Geothermal(Heating/Cooling Rehm) Other(explain under 921 Remarks) mom TO DESCRRIPTtON edor, smllroeg etc
_ t� n � 0 a' av C Ski
4.Date Well(s)Completed: Well ID# J�`b 6 T ) 1t A o nit ee,4'.WA e t4- ✓ r0
Sa.Well Location: AO
tti tt
�r icily �pc,�er1
Facility/Owner Name Facility ID#(if applicable) ft. tt
It. IL
>r IL 1-
physi�Asa—,City,-it Zip
He- 0`�y V ri 3rls zL REMAIucs
r
County Parcel IdeatifcationNo.(P"
5b.Latitude and longitude in degrees/minatedseconds or decimal degrees: .; r CCa3s,n' Unit
(if well field,one Wong is sufficient) n Certification: D`+f R Section
��ile. oZ1 `�b9 N NZ �'a 4k 96% W O°' Dy
L >? 9 _
6. s the wells ermanent or _ Tem ra Signadue of ' ' ed Well Contractor Date
Is(are) ()�' O Po rr
By signing this form,I hereby cemfy that due weff(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or EpNo with IBA NCAC 02C.0100 or ISANCAC 02C.0200 Wed Consnrtctim SYandards and that a
,((this is a repair,fdl out brown weAconstruction information and explain the nature of the copy of this record has been provided to the well owner.
rgwtr router#21 remarks section or on the back of thisform.
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
i
construction,only 1 GW-1 is needed Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1 �^ �J^ SUBMITTAL IN
9.Total well depth below land surface: J 17 (D-) 24a.For All Wells: Submit this form within 30 days of completion of well
For muh0e weAs list all depths f d jferent(-anple-3®200'aid 2@100) construction to the following: I
10.Static water level below top of casing: 20 UP Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter. 24b.For Iniection 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- A/Q o-r#S ki construction to the following:
(Le.aug-,rotary;cable,direct push,etc-)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELIS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
1
13a.Yield(gpm) Method of test: n112 24c.For Water Supply&Injection Well. Da 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: S`� D?i' completion of well construction to tine county health department of the county
where constructed
Form GW-1 North Carolina Department of Erivisonmzntal Quality-Division of water Resources Revised 2-22 2016