GW1-2021-05334_Well Construction - GW1_20211013

WELL CONSTRUCTf ON RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
—Topr j n 14 WATERZONU
Well Contractor Name FROM 7 TO DESCRIPTION
NC Well Contractor Ce,tifieation Number uffietased
_ GJL 1 �021 15.1'OUTER FRm TO J DIAMETER awnOTHICKNESS a nMATERIAL
"'V 1�-RC i� CBE 11�1 ft. & in.
Company Name •
^. .1O{J�r'at1on�sgdkon 1G CASING ORTUBING eothermal closed-loop)
2.Wep Coiistriltdon Pemdt#: D�ti� EOM TO DIAMEM I MUCKNUS MATERIAL
List all applicable well conslruclioP pefWuJix.U1C,Cmmg,,State,Variance,etc.) R• ft. !m
3.Well Use(check well n``se): ft, ft. in.
�,„.p,.
Water So ly WeU . :° 17.SCREEN
g ._ FROM I TO DIAMETER SLOTSIZB THICKNESS MATERIAL
Agric �out al, [3M ipal/Public p Ft. ft. in. -
Geothermal(IIeafmg/Cooling Supply) esidential Water Supply(single)
ft. ft. fu.
IndustriaUCommercial DResidentiai Water Supply(shared) 1L GROrnc
Ilri ati0n FROM TO MATERIAL EMPLACEMENT METHOD�&AMOUNT
[Geothermal
ter Supply Well-` ft. it. I i
ring Rewv ft. ft.
Weill;
FL ft.
Aquifer It e ec4arg Groundwater Remediation
19 SAND/GRAVEL PACK if licoble
Storage and Recovery E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Test 13Stormwater Drainage ft �
ental Technology Subsidence Control ft. ft.
rmal(Closed Lo9p) 13Tracer 20.DRUMING LOG attach additional sheets if n
rmal HeatinglCoolin Return) J Other lain under#21 Remarks FROM TO DESCRIMON inter hanines,sow,ock mze,etc.
ft. 7 -Alt
fL
\; 4.Date Welt(0'Completed: 'r Wen DJ# ft.
ft.
sa.Well Lbcation:
Faci/it/Owner Name JI Facility lD#(if applicable) / ft. ft.
Physical Address,City,and Zip ft'
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/n lnutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) �� 22. tifieation:
'0 to p oermanent
9i'i eW Ag�6.Is(are)the well(s) or Temporary :gn of Certified We 1 r Date
Y' By signing this farm,I hereby caWb,that the well(s)was(were)constructed in accordance
7r1s this a repair to an e:dstii3g,wall: Yes or � with I SA NCAC 02C 0100 or I5A NCAC 02C A200 Well Construction Standards and that a
: If this is a repair,fill out brown well construction information and exptain the name of the copy of this record has been provided to the well owner.
repair under#21 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 1 GW-I is.iieeded. Indicate TOTAL NUMBER of wells construction lion details. You may also attach additional pages if necessary,
drilled: ^� SUB t 1NSTR c C N9
9.Total well depth below land sort ce: �V (fL) 24a.For An Wells r Submit this form within 30 days of completion of well
For multiple wells list all depths if dioerent(example-3©200'and 22@1001 construction to the following:
10.Static water level below top ofcasing: '�7 ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use^+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter.�Q_fL_(in.) 24b.For Iniection Wells: In addition to sending the fort to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Wafer Resourcm.Underground Weega.Control P—S -n.,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)_ Method of tesU 461Qy s. ` dkic.For Water Sappty&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: 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
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