GW1-2021-04581_Well Construction - GW1_20210429

WELL CONSTRUCTION RE( `D(GW-1� ��� For►ntemal Use On'
1.Weil ntractor Informati n:
?/AWATER ZONES
well Contracto ame � p_ �5\ Ro+t To I txGRlrrl
g/ VV Oe
/ UL . �eCC, ft. R. i
NC Well onttactor enification Number �0\Q' t5.0UTER CASING for multi-cased wells OR LINER if a Ikable
TO D A�IETER THICI4�ESS . MATERIAL
Q ft-
R n.
Company Name 16.INNER CASING ORTt><iING eothermal closed-loo
2.Well Construction Permit fl: �I Jh�('Jp�Cb ' d 7� FROM I To I DIAMETER I THICKNESS MATERIAL
List all applicable❑rll.constntctidn permits(i.e.U/C.Count•,State.I'ariance,eta) R R In.
3.Well Use(check well use):
Water Supply Well: l7.SCREEN'•f
FROM TO DIAMETER SLOTSIZE THI MESS J JAIATERIAL
Agricultural OMunicipal/Public SL " In. C Uc
Geothermal(Heating/Cooling Supply) idential Water Supply(single) in.
Industrial/Commercial Residential_Water Supply(shared) 18;GROUT
Irrigation FROM TO MATERIAL 'EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 R' d �"
Monitoring Recovery R. R.
Injection Well: R, ft.
Aquifer Recharge ©Groundwater Remediation
19.SAND/GRAVEL PACK f a llcable =
Aquifer Storage and Recovery O Salinity Barrier FROM TO I MATERIAL EMPLACE EN METHOD
Aquifer Test ostonnwaterDrainage t. Dtt.
Experimental Technology E)Subsidence Control
Geothermal(Closed Loop) 0Tracer 20.DRILLING LOG(attach additional sheets if necessary
FRO?S TO DESCRIPTION Rolor,hardness.soufrockt e. min slye.eta
Geothermal(Heating/Cooling Return) Other(explain_under=2i R�±�) fr
4.Date NVell(s)Completed: \DV�[D4 k. ft.
5 WellET
' _
In f V) Q R.
Facility/Owner Name Faclit IDN(if pplicab ) R• ft.
R. ft.
Physical Address,City,and Zip
Z I.ttEMARKS
Pz
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/ntinutes/seconds or decimal degrees:
(ifcvell field,one tat/long is sufficient) C t/� �� 22.Certification:
N _22 13 XW Boa
6.Is(are)the well(s) ermanent or Temporary Stgnatti led Well Contmc or Date
By signing this fornt.I hereby certh,dint the uell(s)was(were)eonstritcred,it accordance
7.Is this n repair to an existing tycll: Yes or No with 1 SA NCA.C.01C".0100 or 15A:NCAC 02C.0100 Nell Construction Standards and that a
if this Is a repair fill out Rnoi n well construction information and explain due nature of the copy of fit is record has been provided to the nr(I'I I r.
repair tinder#21 rematics section or on the back of this fort. 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-t 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: —(ft•) 24a. For All Welts: Submit this form within 30 days of completion of well
Fa-multiple i ells list all depths 1)'d(Qerent(example-J@200'and 2@100ff) construction to the following:
10.Static water level below top of casing: !O D (ft.) Division of Water Resources,Information Processing Unit,
If utter letvl Is above casing.use "/1 1617 Mail Service Center,Raleigh,NC 276994617'
11.Borehole diameter:7 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this font within 30 days of completion of well
12.Well construction method: &A04 construction to the following:
(1.e.auger,rotary.cable,direct push etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: �� 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) D Method of test �^�`�L 24c. For Water Supply&Infection Wells. In addition to sending the font to
the address(es) above, also submit one copy of this form"within 30 days of
13b.Disinfection type: Tit Amount: D completion of well construction to the county health department of the county
where constructed.
Fomi G W-t North.Carolina Department of Environmental Quality-Division of Water Resouiccs Revised 2-22-2016