GW1-2021-06576_Well Construction - GW1_20211029

WELL CONSTRUCTION RECORD(GW-I), For Internal Use Only:
1.We Contractor Information:
r7 U PoLI i t e` ,14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
q - —A 11 s ft '1 7 ft.
ft. ft.
NC Well Contractor Certification Number
1.OIITF,R CASING'( multi casedwens`UR'IJNER'"[f a"'licable
(Job�, 's'(,�e f I pull l i hq FROM TO DIAMETER THICKNESS MA''T!!E//RIAL
Company Nam t �0 m• /�/ V C
/{� I6`INNER:CASINGORTUBING' 'eothermalMased-loo"'_y _
2.Well Construction Permit#: l `3 ff y FROM TO DIAMETER I THICKNESS I MATERTAI
List all applicable well construction permits C1.e.UIC,Count};State,Variance,etr-) ft• ft. in.
3.Well Use(check well use): It.
t It
in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSITd THICKNESS IA MATERL
±AgriculturalMlmicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) (Residential Water Supply(single) ft. ft. in.
(_ Industrial/Commercial OResidential Water Supply(shared) 18:.GROiTf- ;
711rrigation FROM TO MATERIAL'. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 2� ft. 3/� �� )our
Monitoring DRecovcry ft. tt. Jr r
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery OSalini ty Barrier "'19 SAND/GRAVEL PACK rf:" 'licable
FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer _-'20 DRILLING.LOG attach additional sheeii:if-necessa
7.Geothermal(Heating/Cooling Return) Other(explain under#2l Remarks FROM TO DESCRn'TION(color,hardness,soillroek type, fain size,etc.)
/y ft. 10
ft. G�ff U('d er} oral VC l
4.Date Well(s)Completed:?-yG-2� well ID# PO vr 300
5a.Well Location:
RGv fin/ 5�fphPns ft. ft. ic
Facility/Owner Name Facility ID#(if applicable) h• ft.
ac
`40 1 ya 115 Acres
cues Dr larm m U06 ft. ft.
Physical Address,City,and Zip G,,�q R ft. tCt ly�lli
A5A !Q Z5✓ 27001 C 21:REMARKS r ?Q
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wcll field,one lat/long is sufficient) 22.Certification:
N W
6.Is(are)the well(s) , Permanent or Temporary Signature of Certified We tractor Dam
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or PRNo with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out brown well construction information and explain the nature of due 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 300 (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example--�3@200'and 2@100) construction to the following:
10,Static water level below top of casing: 5—
(ft) Division of Water Resources,Information Processing Unit,
ljwater level is above casing,/up s'"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter:l� ��l (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
n) above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: / R•r A C4 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
1 [ 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) I Method of test:�r,r 1� T 7l' 24c.For Water Stmnly&Iniectio i Wells: In addition to sending the form to
the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type: 1"1 d'1 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