GW1-2021-06295_Well Construction - GW1_20210915

\ GW-1 For Internal Use Only:
WELL CONSTRUCTION RECORD
1.Well contractor Information:
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DESCRIF'ITON
WellContractor Name FROM ft. TO
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NC Well Contractor Certification Number ~ �Cr=r'�G�O� :;I3 OUTER:C"IN01 fer mo aitDd rdb;011 1t.d 3
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Company Name �`° 1G-INNBR CASING ORTITBING. tl+ . .,... "
2.Well Construction Permit#: FROM DIAMET7�ft fL in. MUCJ MATkAW.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc)
ft. ft. in.3.Well Use(check well use):
lGeothermal
Supply well: - - --
PP FROM TO DIAME-fF.R SLOT SIZE Tffil'2�iESS MA1E1tIAL
cultural �MtuticipaUPublic 0 ft. 3OUthermal(Heatirtg/Cooling Supply) esidential Water Supply(single) ft. fL instriaUCommercial Residential Water Supply(shared)"on FROM TO MATERIAL EMPf. CEKENT OD&AMOUNT
Water Supply Well: ftQ ft 40 1e 0 rnitoring Recovery fL fL
ion Well: fL fcifer Recharge Groundwater Remediationifer Storage and Recovery Salinity Barrier FROM To MATEffiAL EMPLACEMFI'rrMETHOD
ifer Test 13Stormwater Drainage fL fL
erimental Technology Subsidence Control & fL
Geothermal
Cleatin Coolin Return Otherr(explain under#21 Remarks FR.,M iI T I oG ell oESCR nai ON(color ' wr
(Closed
Loop) � FROM 1'O DFSCRIPrION eobq hardam,rdlheek tee,etc.)
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4.Date Well(s)Completed: Well ID# U ft.
5s.Well Location: (r d ft- �0 ft' SOII
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Facility/Owner Name Facility ID#(ifapplic ble) fL ft
1 L-4SSi-kc(- Rrmes4e0(d �n7�N(I fL ft..
Physical Address,City,and Zip fL fL
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County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreesiminates/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
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6.Is(are)the well(s)ofermanent or OTemporary Signature of Zied Well Contract Date
By signing this form,I hereby cerr fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or 1Pio with 15A NCAC 01C.0100 or 15A 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 911 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:
? L/ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ✓ / (ft.) 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:
10.Static water level below top of casing: t9 0 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) i
/ 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12 Well construction method: RF 4 QC�! above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center;Raleigh,NC 27699-1636
13s.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
1 the address(es) above, also submit one;copy of this form within 30 days of
13b.Disinfection type: /IT Amount completion of well construction to the county ihealth department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016