GW1-2021-03829_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information:,,
�l 14.,WATERZONES x.;
We1lCoahactorName FROM TO DESCRIPIla,
1 t. sat. l it oc.
z-&O 14 ft. ft. I
NC Well Contractor Certification Number
r35B.011TER:CASING form6ld;i"d:aelid ORLiNER s""Geable" t :7 r:;
FROM TO DL4MUER THICKNESS I MATERIAL
ft tn.
Company Name
x16 INNER' ING O rz,R:TUBING: eSthermal:elaaed=loo , " t.
2.Well Construction Permit#: ® �/ I FROM - TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County.State,Parlance,etc.) ft. ft.
3.Well Use(check well use): % & in.
Water Supply Well: M SCREE Nv° ?r....: Y r.rr+,i.<.,u.•, ,i .::>�
FROM TO I DIAMETER I SLOT StzE I THICKNESS I MATERIAL
Agricultural cipaVPublic 0 f. ft in.
_. Geothermal(Heating/Cooling Supply) DResidentiai Water Supply(single) & ft,
h
:)Industrial/Commercial E)Residential Water Supply(shared)
�:18:GROUT.rv�us;< r a 2.. fJi "ZI.-
71hrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 10
f�
Monitoring 01tecovery & %
Injection Well:
SAN&D/GRAVEL'PA ft.
Aq here �G%dwaRemediation
Aquifer Storage Recovery E) •ty � FROM To C K MATERIAL
HRaUabL e .:...._ h za:.:.�,.. �.x:�u 1:..• �.,., ;�:
EMPLACEMENT METHOD
Aquifer Test OStormwaW Dminage &
Experimental Technology DSubsidence Control ft. R
Geothermal(Closed Loop) DTMW 40.'DRIEZ,U4G I.OG'attaEti iddidiii I'ahixttifiiecis'
Geothermal(Heating/Cooling R ) Other(explain under#21 Remarks) FROM TO DESCRIPTION cobs bud wWrotk etc
f Q ft. r t`
4.Date Well(s)Completed: �C Well ID# i ft ft.
5a.Well cation: 14�t fL
Ci 9/r/5 (f CCA fL c ft. �<
Facility/Owner Name _ Facility ID#(ifapplicable) ft. ft.
7 7co r`� ft
Physical Address,City,and Zip M/�(' '�/ ,_f� ft' ft a t
`e Ck-I ��v�[�/raJ!' avREK4RKS:.' 3- p.s .�: xa ,J+ �i•s r:« , x
County Parcel Identification No.(PIN)
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
_ rcafS(7 J'V511
(ifwell field,one lat/long is sufficient) 12. ad
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N W .�
6.b(are)the well(s) Permanent or 13Temporary i re ofCertified Well Con or Date
B>VJgning this form,I hereby lhall the wells)was(were)constructed in accordance
7.1s this a repair to an existing well: ElYes or EINo with ISA NCAC 02C.0100 or ISA NCAC 01C.0200 Well Construction Standandr and that a
If this is a repalr,fill out known well construction Wormation and explain the nature of the ropy ofdtls record has been provided to de'well owner.
repair under#21 remarks section or on the back ofthis 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
402
9.Total well depth below land surface: _ e 00 24e.For All Wells: Submit this loom within 30 days of completion of well
For multiple wells list all dept/ts tfdifferent(-- - @290' -d 1(a)100) construction to the following:
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10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwaterlevel is above casing rise"." 1617 Mall Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
�p f ray above,also submit one copy of this!fort within 30 days of completion of well
12.Well construction method: [�-t !S�9 J construction to the following:
(Lt.auger,rotary.cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY/WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 276994636
13a.Yield(gpm) r Method of test: P , 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
136.Disinfection type: Amount: completion of"well construction to the county health department of the county
where constructed.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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