GW1-2021-03581_Well Construction - GW1_20210823

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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n111$Qp� (11f ��G� FROM
WATER i (
FROM TO DESCRIPTION
Well Contractor Name � ft. 2/-Oft- �L�
YO u ft. , lD tr.
NC Well Contractor C'enitication Number 15.OUTER CASING for multi-cased wells OR LINER(if applicable)
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� FROM TO DIA�f ETER' THICKNESS MATERIAL
A'W 5,VI„v �st C • fit. ft. in...
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Compam Name 16.1\\ER CASING OR T(iBING eotherinal closed-1
2.Well Construction Permit#: �t7 a ob
l
OU 3 013 FRO\1 1 TO DIAMETER! + THIC6\ESS MATERIAL
1 — ft• I ft. ZS- lin.' �,p Z 1 IPVG
L[cr rill a/,plicr[Idr r.�%i�.ur,lrrrellon pe'r!)Cl.e R.tt(%1(•,r"u[u,n..vure. I irnunrer.r/r.r
ft. ft.
3.Well Use(check well use):
17.SCREEN
Water Supply M ell: FROM TO DLAMETER SLOT SIZE THICKNESS MATERIAL
AgrlCUltUral ®M icipaliYublic ft. ft. in.
Geothermal(1i a?me%Cooling Supp1)'1 esidential Water Supply(single) ft, 1 fr. in.
Industrial/Con- rr,.1' [DResldential Water Supply(shared) 18.GROUT
FROM I TO MATERIALI EMPLACEMENT METHOD&A,NIOUNT
Irrigation U (�t'�
Non-Water Suphh Well: ZU RR/1- t
Moniibnng [3Recovery ft. ft. (yh,
Injection\Well: t'r. I ft.
Aquiier Recha:_c ®Groundwater Remediation
19.SAN WG RA V F,L PAC li((f a l licablcl
Aquifer S?Or3'�c ciC?d Recovery Salinity Barrier FROH l'0 �faTER1AL ' Ey1PLACE'11EVTME"fHOD
AquiterTest []Storrn%%ater Drainage tr. ? f[.
Ea Experimental i.cnno.ogy Subsidence Control
pe ' '
Geothermal(Clo.m:�i.00p) Tracer 20.DRILLING LOG(attach additional sheets if necessa ')
FROM TO i DESCRIPTION icolor•hm1•dness.soilhrock t- e.Erain size,ete.)
Geothermal(I-i: !:niz:Cooline Return) Other(explain under#21 Remarks) I! ft. + fir. ( CIS o VC I'-10tAf-CU
4.Date Well(s)(ompleted: L 13 -a ` Well ID# ( �i/ f'• ! ft.
ft,
5a.Well Locatir:n:
22 ft.
FacilityOwner Mn:c Facili;� ID�lifapplicablel
20� 1l �a YCdrde" NG <�
ft. fit. � �()���~r`4jf-+'
Physical Address.Cit..;.I'.ZIP
%3/-ll 9399 MO D 21.REMARKS \
Count Parcel Identification No.(PIN;
5b.Latitude ant_iongitude in degrees/minutes/seconds or decimal degrees:
(it\yell field•one kv lon_rs sufficient) 22.Certification:
attire 04 Cel Tied Well Coniric!oI Date
6.Islam)the weii(s)0 ermanew or OTemporary
)n-m.1 hcreht c utr Ilrur Iha,:rl!t.V uus!nrrei rulas!n:cved in accordance
7.Is this a reps to:art existing well• rJYes or o th! .)• t !( a2t' ri!(!r,nr!;t �rt'.4r'a2t' u'nu Ifel!('n,r,rrucnon Slnndurde rind that a
Ifthu r.c a repair._. ur ti ninny I, /!rurr.rru<nun'n,fnrnxrnol,and,'xpinur the nature•of fli opt nt Ilrr.AV Ord hu,been err,vd t1 to rHc a i!under
repwr inrder 1hr.c,lhr•nr. 23.Site diagram or additional well details:
8.For Geoprobe!DPT L Geothermal Wells having the samert
You ny use the back of this page to provide additional well site details or well
r or Closed-Loop
construcumt details. You may also attach additional pages if necessary.
construction.on( -1 is needed. lndicate'I'OTAI.NUMBEIR of wells
drilled: SUBMITTAL INSTRUCTIONS �
9.Total well depth below•land surface: �i aS (ft•) 24a. For All Wells: Submit this torin within 30 days of completion of well
li,r nuduplc•a•rlla;.,,rr„rA•;v1rs r,..a/i(:r,�n/sang>le--i!i[:�l1(!'dnd'-'�r!ll(I'1 construction to the l'ollowing: j
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10.Static water a"0 below top of casing: (ft.) Uiyision of Water Resource's,Information Processing Unit,
Ifnat rlarel rsun ..,.;r„,rce" 1617 Mail Service C inter.Raleigh,NC 27699-1617
11.Borehole diameter: (�O. 2 S (in.) 24b. For Iniection Wells: in addition to sending the fibrin to the address in 24a
above.ai o Submit one copy of thi t torn within 30 days of completion of well
12.\Well constrt_L6wi tnethod �
: D construcu•On to the follov:iniz i1
ii.e.auger.rotaq-.r.:^!c.direct push.etc.r
Division of Water Resources,Underground Injection Control Program,
FOR Xi'A'1'ER i I'l.': tWELLS ONLY: Mail Service Ceinter,Raleigh,NC 27699-1636
13a.field(gpnrt_y�h Method of test: In2r 24c. For Water Sunnly& Iniection Yells: In addition to sending the form to
t the addre:s(es) above. also submit:ohe copy of this form Within 30 days of
13b.Disinfectio!r tyaa ` i�1Qt Amount: Q . completion of well construction to the' county health department of the county
where constnlcted.
Fonn GW-I North Carolina Depvttinent of Environnient it Qtuili:\-Di tsiau of Rater Rc bites G Revised 2-22.2016
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