GW1-2021-02369_Well Construction - GW1_20210527

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information::
(5��� A16/*� 14.WATER ZONES
Well Contractor N e FROM TO DESCRIMON
d ft. Z Z ft' /Q
© fL fL
NC Well Contractor Certification Number 15.OUTER CASING for mniti,cased wetly'OR LINER'1f cable),
I e is A601 C 1 ICl/ CC). FROM TO D TER THICKNESS MATERIAL
�yy6�] 1 (ilJ 1� O ft. Cr 2 ft. ' in. 1
Company Nam(
16.INNER CASING.OR TUBING Wothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well conshuction permits(i.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER, SLOT SIZE THICKNESS MATERIAL
Agricultural E]Municipal/Public fL ft, in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft, io:
:)Industrial/Commercial Residential Water Supply(shared)
18.GROUT
hti ation FROM I TO MATERIAL EMPLACEMENT.METHOD&AMOUNT
Non-Water Supply Well: 0 ft. Z G fL
Monitoring DRecovery ft. %ft. ft. ,
Injection Well: I. 0amem
Aquifer Recharge OGroundwater Remediation
Aquifer Storage and Recovery Salim Barrier FROM
SAND/GRAVEL PACK>If A MATERIAL
q g Dry � ty FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStonnwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20:'DRILLING LOG attach addidonai.sheets 1f aceessa
Geothermal eatin CoolingRetum) nOther FROM TO DESCRtMONcolor hardn gall/rackIn etc lain under#21 Remarks) Q ft. .L ft. '� d Ol�f
C 7-54.Date Well(s)Completed:•/ - Z 0 af Well M# z ft. ft ��
Sa.Well Location: ft' )La.S ft' / 061r,
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft' ft
_71 U rd Sp rtn4 ligp ,. a7161'Z-
Phys
ical Ad City,and Zip N L ft. ft.
t \t r ( 21 / To0 1,l- 76 21:REMAM'
County Il Parcel lIIdentifcation'No.(PIN)
Urkil
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
er.Certification:
(if well field,one Iat(long is sufficient) 22 �/
N W ,/J f 2&.L,
6.Is(are)the well(s)GPermanent or OTemporary Signature of Certified Well Conlractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: nYes or No with 15A NCAC 02C.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 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1 2 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 doerent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 0 VL) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+^ el 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
v above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: l 6 r/ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 17699-1636
13a.Yield(gpm) ` y Method of test: 1 /d W 24c.For Water Supply&Infection 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.
Font GW-1 North Carolina Department of Environmental Quality-Division of Water Resourcesi Revised 2-22-2016