GW1-2021-05429_Well Construction - GW1_20211013

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
SEAS OK 061t t 14.WATER ZONES
Well Contractor Name ��, y FROM TO DESCRIPTION
A �� J TO ft ft.. 0 ft. 5 ID Vh
ft.
NC Well Contractor Certification Number O e On FgEVNER
TO ft. DIAMETER wells OR LINER a licable egg- OUTER CASING for matti�ased
lr a ik,
� Cn ER THICK MESS MATERIAL
Company Name 56 to PV G
Y l 1CASINGOR TUBING eothermal closedaoo2.Well Construction Permit#: FTO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(Te.VIC,County,State,VariG'ttte,etc) ft ft tn.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FRO 37.SCREEN
M TO DIAMETER. SLOT SITE THICKNESS MATERIAL
Agricultural unicipal/Public ft. R. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18::GROUT
1ni ation FROM TO MATERII,AL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft .p ft. a:•IO N t t L t
Monitoring Recovery ft. ft.
Injection Well:
ft, ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GitAVEL PACK if a liceble
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer'Test OStormwater Drainage ft• Ri
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 2o:DRII I ING I OG attach additional sheets if:necess
Geothermal eatin Coolin Return) rl Other(explain under#21 Remarks) I FROM TO DESCRIMON color,hardn soil/rock e,grain dze,etc.
1 0 +�. i o i✓1 a.
4.Date Well(s)Completed. Well ID# h a a ft. 0 tt. A h t 1,
5a.Well Location: �10 tt' 0 ft' irQlil l � G ft.
� MA(5�&fy\ A ft. ft.
Facility/Owner Name Facility IN(if applicable) ft. R•
� y 13 Wc�atil� �� �1c����►.N�'a-�591 ft. ft.
Physics dress,City,and Zip
- d •`\5T0 n 21.REMARXS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one tat/long is sufficient) 22.Certification-
N W ZI
6.Is(are)the well(s)&ermanent or OTemporary Signbohe of Certified Well Contractor Date
By signing this form,I hereby certify that the uwll(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or QJNo 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#11 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' ( Q(( SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 v (ft-) 24a. 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 to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level Is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one cagy of this form within 30 days of completion of well
12.Well construction method: fro 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: l 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: low 24c.For Water Supply&Injection 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: J completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016