GW1-2021-03576_Well Construction - GW1_20210823

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor information:
S LYl la.WATER ZONES
FROM
TO IDESCRIPTION'
Well Contractor Nawc ft. &V ft. I 14 O1 0L,>
Lpg3 - ft. • ft. ` F
NC Well Contractor(,cnitication Number 1S.OUTER CASING(for multi-cased µells OR LiNER(if a licablel
�,,.� w ��• ^C� Y� FROM TO DIAMETER i - THICK,NESS iNIATERIAL
fi. ft. Alin.'
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Company Name 16.INNER CASING OR TUBING othgt mil closed-too
n FROM 1 TO DIAM ETERI THICKNESS IAL2.Well Construction Permit#: 90A0_ r)b9r__1� ft ''11 fL C
boall applicable "rA r.�rr,lrrrrf7olr pPl7r7!(.;Il.t'.(!l(',Ctuun;..Su,e, I in'nmrr.r1r.r O '1416 •2•S l�
ft. I ft. in.
3. Well Use(check"ell use):
17.SCREEN'
Water Supply NN ell: FROM I To DIAMETER suer s¢E THICKNESS MATERIAL
A_ncultural ®Mon al/Public ft. ft. in.
Geothermal(Flcating;Cooling Supply) e,deritial Water Supply(single) fr, ft. in.
Industrial/Con-.:ner.ial nRes!dential Water Supply(shared) Ig,CROI:T
FROM I TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Irrigation n
fr. �hk I
Non-Water Supply MQII:
Monitoring Rccoter\ ft. ft. '
Injection Well: ft. I fr. l
AyuiferRechu:_: ®GroundwaterRemediation t9 SAhD!GRA\'F.LPACt:(ifa licable)Salinity Barrier FROM .0 MATERAAI: F.�IPLACENIENT mErHOD
Aquifer 5toragc and Recovery !
Aquifer Test
®Storm"ater Drainage fr '• ft.
Experimental :ccrna!ogy nSubsidence Control I ft. ft. i
Geothermal(Ci.ise:i.00pj OTracer 20.DRILLING LOG(attach additional sheets if necessa ,)
FROM TO DE, PTI \(color.hardness.soil/ ck rain size.etc.
Geothermal(H.eta,erC'oolinPReturn) ' Other(explain undcr#21Remarks) i ft. ,y(r-fft. iC( ��x
4.Date Well(s)(ompleted: Well ID# �I 1 41v fr ; 74
re. ft.
5a.Well Locatir.:i:
ft, fL
r�
Facility-Owner e Faciliy (ifapplicable) f•
lU • ft. �e''�� w
1 j f:. ft i �d
AY•cVe �te-9- o��Z�s I ft-7ft. L� t1
Physical Address.('in.e.nr.Zip q p 1
(�(p4 21.REMARKS
County Parcel Identification No.IPIN;
5b.Latitude any iovq)italde in degrees/minutes/seconds or decimal degrees:
(if well field.one k, long is sufficient) 22.Certification:
g` ' rernn.neiit
8Z�41 21• glcoyS2 G 8 7 2ef
laturco!Certified Well Conir.,c!or Dat6.Is(are)the weji(s) or Temporary
lit• ua.Larne 1 lurehr ccrr!fc d,ul Ih.•ur//Cy vu..hrerci cun.rtnrded in ac•er,rc/anee
7.Is this a repe''to,::n existing µ'ell• ®Yes or 0 ,rah I':I.1i'.�('u?t'.rilllU ur!?A.\'('A('b?('.fJ?rlh(fell('nnco•ucuo,i Standurdc and(bat a
/flhis t., I relrinr. nr: r rtrn in//cnr,.rr ru�ruu urfi,rnurnan<nu/.:rplmo the nrurrrc•nitln tips'u!dr.,rec aril/nr. been pnn nkd to nc�ur/I uu„er.
repair under '/rr.r.::"••velum or w,Me hack al this/brn,. 23.Site diagram or additional well details:
8.For Geoprobe!DPT or Closed-Loop Geothermal Wells having the same You In ay use the back of this page to provide additional well site details or well
construction.Oi;l• 1 is needed. indicare'T'OT.41..NUMBER of wells
construcuon details. You may also attach additional pages if necessary.
driiled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1�'f� (ft-) 24a. For All W Its: Submit this(torn within 30 days of completion of well
Foruuduple well.,t.a a.,dr�dre tt d1.11rrrrn ic:vump/e-.;sir•?I7G'and hiPlUll'I construction to the Hollowing:
i
10.Static water to c'helots'top Of easing: I L4 (ft.) Division of Water Resources.Information Processing Unit,
If wilier level l.c an•r,::•,.,;,u..e" 1617\jai!Service Celnter,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For injection Wells: in addition to sending the tone to the address in 24a
above.aiso submit one cop% of thi g forin wi''ihin 30 days of completion of well
12.«'ell constr:.:riGh method: f5�G►t`k - constrtict::,n to the following:
ii.e.auger.rotas-.c:,r!e.,i!rctt push.ct.
Division of Water Resources,l:ndergrodnd Injection Control Program,
FOR y3ATER`:FVi.`t WELLS ONLY: 1636 INfail Service(enter,Raleigh,NC 27699-1636
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13a.Yield(gpml _ 'Method of test:Gak- CA1%�3�r`- 24c• For Water SupplyS Iniection,Wells: In addition to sending the form to
` J the addresses) abOVe. also submi{ one cop% of this form within 30 days of
13b.Disinfectionry aH; C� N�>Z Amount: completion of well construction to.thi county health department of the county
where constructed.
i
Fonn G1\'-1
North Carolina �
Department of Environmental Qtalit\-Dit ision of Water Resources Revised 2-22-2016
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