GW1-2021-03911_Well Construction - GW1_20210823

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WELT.CONSTRUCTION RECORD(GW7-1) ,� For Internal Use Only:
1.W 1 Contractor Information:
i
,3 Qt►� !nWATIERZONES
ll Catrtrnetor Name ' (�J eci3;P� �DOR'FROM TO n7 - P�C� <r'� toy`�J,
NC Well Contractor CertificationNumbe( n�
��� 15.OUTER CASING for ttsttltftasM evils OR LINER i n61e
I,Jck ��.Ut7 FROM To DIAMETER 7'iQCRT'FSS MATERI��
'r" R. P
otnpany Nam r� 16.INNER CASING OR TUBING(geothermal
2.Well Construction Permit#:l024' O a001/Z 2 FROM TO DIAMETER THICKIiESS I MATERk4L
List aH applicable wit construction permits(ire UiC.Counht State.Varlafiw.ele.) it. n in
3.Well Use(check well use): fL 1t la
Water Supply'*Veil: 17.SCREEN
FROM TO uLRMETER SLOTS= THICKNESS MATERIAL
Agricultural [MunicipaUPublic n tr. fe
thermal(Heating/Cooling Supply) ffWesidcntial Water Supply(single) rr. tl. is
:)Industrial/Commercial Residential%later Supply(shared) 1&GROUT
'Ibrixation FROM I TO MATERIAL EJMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: °- ZU ft- 1401e 14 Poo ircd
Monitoring Recovery n ft.
Injection Well: ft. ft.
Aquifer Recharge [Crroundwater Remediation
It.SAND/GRAVEL PACK f a le
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT hIffHOD
Aquifer Test []Stormvtater Drainage R- D•
Experimental Technology [Subsidence Control 8. it.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheM 1f neeessa
Geothermal Heatin Coolin Return) nOther(explain under#21 Remarks) FROM rt. n.To DESCRIPTION caor,harm,sotbroct qpa.g3fa tire.etc
4.Date Wells)Completed: 2-4 WeU IDl# rL R'
f3. ft.
Sa.Well Location:
Mg t i s it l;)l;ka rx n
Facility/Owner Name Facility m#(if applicable)
n ft,
.N 3 41 /'f At m tf v i a h _ ft. ft.
Physical Address,City,and Zip
ft. tit.
Rig(%Aa vtlk 5?417 21.REMARKS
Canty iPaml Identification No.(P1N)
5b.Latitude and longitude in degrees/minutes/seeouds or decimal degrees:
(if well field,one lat'long is sufficient) 22.Certification:
N Vi'
2a2
6.Is(are)the well(s) Permanent or [Temporary S' .ofCeYti6ed well C factor Date
BJ,signing this form.I hereby ceniify that the nirll(s)it-as(note)constructed in accordance
7.Is this a repair to an existing well: [Yes or []No u9th IJA NCAC 02C.0100 or ISA NCAC 02C:0200 Well Construction Standards and that a
If this is a repair,fill out known xe/l construction information and eaplant the nature o/the ropy aphis record has been prarlded to the well owner.
repair under 021 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: S BMI7TAL tNS7'RUCTIONS
9.Total well depth below land surface: (o (ft) 24a.Lor All We Submit this form;within 30 days of completion of well
For multiple µells list all depths ifdifjermt(eumple-1@200'and 2@1001 construction to the following:
10.Sttstic water level below top of casing: Z a (lit.) Division of Water Resources,Information Processing Unit,
Ifuuter level is abm:e casing,use"+' 1617 Mail Service Center,4Raleigh,NC 17699-1617
11.Borehole diameter. 6 (in.) 24b.F"IDieetian Wells: In addition to sending the farm to the address in 24a
12.Wed construction method. /Q T i r Kule above,also submit one copy of this form within 30 days of completion of well
(ic.auger,rotary,cable,daccr pleb.etc.) construction to the following: I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,1 Ralefgb,PIC 27699-1636
13a.Yield(gpm) D Method of(est: __d f1 MT 24c.For Water SuDuly&Injection Wells: In addition to sending the fort to
the addresses)above, also submit one I copy of'this form within 30 days of
13b.Disinfection type: SA OC,k Amount: 3.5"' completion of well construction to the county stealth department of the county