GW1-2021-06329_Well Construction - GW1_20210915

WELL CONSTRUCTION RECORD GW-1 For internal Use Only.
1.Well Contractor Information: ®°
l�J�I n_�,e E 1,Jc�r-� `t�, 5•� FROM TO DESCREMON'r x..
14:WATER ZONES
Well Contractor Name 4� "'f two + ft log fr �
�13 61+ A
NC Well Contractor Certification Number c(t `
Ue��f�Ct,rJ�`O� FRO DfERC�INGformDIAMI7FeRl:OR MATERIAL
P f® ,j3;'lZ, JQ t fc /2 iL 6 to I 'v^ti Ze
Company Name `J v
�{'� 1G'INNSRCASINGORT4)BING "1> '�' '�;�---- -
2.Well Construction Permit#: I 1 o_sM r1_0M I'o D1nMErIIt7F'i�CKMFss MATERIAL
List all applicable well construction permits(ie.UIC.County.State,Variance,etc.) f fL in.
fLL ft. hu
3.Well Use(check well use):
;17:SCR_EEN
lGeothermal
Supply Well: FROM TO DIAME M ;SLOT SIZE THICSNISS MATERIAL
cultural [3MunicipaltPublic 0 fL �ds" ft.hermal(Heating/Cooling Supply) Residential Water Supply(single) ft. g in.
strial/Commercial Residential Water Supply(shared)
:GROUT ion FROM TOMATERIAL EMPLACIIIfF3V'T METHOD&AMOUNT
Water Supply Well: 0ft ft Gnitoring Recovery ft. &
on Well: ft. ft.ifer Recharge 13Gmundwater Remediation
ifer Storage and Recovery OSalinity Barrier FROM /GRAVEL PACK d T L ALA01)ifer Test [3Stormwater Drainage fr' fL
erimental Technology Subsidence Control fL IL
thermal(Closed Loop) Tracer ;20.DRHJJNG LOG;attach addifiontii sheeta'if(Heating/Cooling Return Other(explain under#21 Remarks FROM TO DESCRIPTION(color,a,raess,.orureck d�
4.Date Well(s)Completed: v " Well ID# L10 IL th S(G r
5a Well Location:
ft fL
o k& A)0&- fL fL
Facility r Name Facility ID#(if applicable) fL fL
"15 Nc. N W Y q. IV ( e( M a
Physical Address,City,and Zip fl. ft.
���nS�d✓� XREMARKS . :. `.
County Parcel Identification No.(PIN) G� Q S / _—Dr;uz oQ
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification-
N W �
6.Is(are)the well(s)QPermanent or OTemporary Sighature ofggR2 Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or [!fNo 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#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:_-/6 J+' (fk) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@1001) construction t0 the following:
10.Static water level below top of casing: �-t/ (ft.) Division of Water Resources,Information Processing Unit,
lfwoter[ever is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: 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: f
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- y 10 t— 24c.For Water Sunoly&Lnieetion Wells: In addition to sending the form to
the address(es) above, also submit one i 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 OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016