GW1-2021-07360_Well Construction - GW1_20210921

WELL CONSTRUCTION RECORD(GW-1) I Use Only:
1.Well Contractor Information-
Cq l'!Q.S Crin .0A 14.WATVR ZONES
X 1,10- �WONI TO DESCRIPTION Well Contractor Naow %.
L 1. 51(0 ft. Pb I I
ID 0(3,-
NC Well Contractor Cerlification Numbei- �\VOcA-'�01 5 9 b
15.OUTER CASING for multi-eased wells icable)
"�R'if ap� NIA .1A 0 A\ESSFROM I TO I DIAMETER i
Company Name W ft. i ft. I in.
16.INNER CASING OR TUBING(Reot ier a[this d-loop)
2.Well Construction Permit 0 FROM I TO DIANICI-ER THICKNESS I MATERIAL
4. 1,- &c-
-A 3.Well Use(check well use): ft. ft. in.
17.SCREEN
Supply'%\ell: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural n u ipalipublic ft. in.
12 Mu Geothermal Obcavna;Coohng Supply) �idl�hlz, r. in.
esidential Water Supply(Single) ft.
lndustrial/Con-..-ien ia! []Residential Water Supply(shared) -18.GROUT
Irripation FROM I TO MATERIAL EIMPLACEMENT METHOD&AMM
Non-Water Sup:)l*v Nl ell: C) fr.T 270 ft. AtfgZ-e j Azi(A
:).Monitoring Recovery f!. ft. ` I I I
Injection Well: r-3,
Aquifer Recha: E3Groundwatcr Reirieditnion
lt9SANIn!LAVEL PACE(Lf applicaTe)
Aquifer Storagv,,rd Recovery E3 Sal inity Barrier 0 , To
MATERIAL I E.MPLACENIENT;METHOD
Aquifer Test [3storm\,,ater Drainage r, ft.
Experimental o,nno!ogy [3Subsidence Control
Geothermal(C*:,iseu 1.00p) [3Tracer 20,DRILLING LOG(attach additional'sheets if necessary)
FROV,.­.i,.i;-.�.`CooIini.;Return) r3Other(explain unde #21 Remarks) I TO DESCRIPTION(color.hnrdntss,soillrock type.grain size.etc.)
Geothermal(H
ft. ft. cia-4
F,.
4.Date Well(s)(ompleted: q- Z1 Well ID# FJJ te 9515 tf
_-7
5a.Well Locatil-,j: ft. ft.
Sum A P+" C�C, ft. ft.
Facility,0wrier\:n,­ Fac i lizzy 1D4 t i f applicable) f!. ft.
0 is - la is fA 4fV1dAY&0v%u;J1( t 0C W717- 11 f.. ft.
Plivsical Address.0i\.;incZrp ft. ft.
21.REMARKS
Count\ Parcel Identification No,WIN;
5b.Latitude and iov-.itude in degrees/minutes/seconds or decimal degrees:
i if well field.one Li lonu i,sufficient)
22.Ce tifica
3570 Z-41 g 3.*737q24p,, 9'2-0 Za' 30.dtlfc(r \\-
6.Is(are)the%veNj b)w4r-nanciit or OTemporarx, ;;0e,111re of Certified Well Cptur.,mor Date
1,*,*/,fin-in,I lwreh.v coriffl.that the Iva.,hrere,consmicted in accordonce
7.Is this a repai-to:aft existing well: ni-es or .'o rjffi 13A.1t'ACI13C.0100 or ItAAVACWC 0200 lVell and dial a
llihoi.\orepaor. du\re,-,,rdho.,been 11ruvidedni the it vilortner.
repror neat er
23.Site diagram or additional well details:
S.For Geoprotic,;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.tit):' ! ('ii-I is needed. Indicate'VOTAL NUMBER of Wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTION'S
9.Total well depth below land surface: ft-) 24a. For All Wells: Submit this t'arm within 30 days of completion of well
hornudople Ire/A i­,,i"I,.Pili,iidi(Jercia constrLIC1101)to the IbIlOIA-Ing:
10.Static wuter't-0 below top o1rcasing: V (ft.) Division of Water Resouftes,Information Processing Unit,
1617 Mail Set-vice Center,Raleigh,NC 27699-1617
11.Borehole diameter. (P. Z V
(in.) 14b. For Iniection XVells: In addition to sending the forin to the address in 24a
above, ai-,,)Submit one copy ofthi- lbrin within 30 days of completion of well
12.Well constrt.rii(,f,method: folloiving
laiy� construcuon to the t:
(i.e.au6cr.ratan.c:;!'!Q.i'lect Push.etc I
Division of Water Resources,Underground Injection Control Program,
FOR WATER St PH.% WELLS ONA.Y: 1636 Mail Service Center,Raleigh,NC 27699-1636
l3a.Yield(gpm) Method of test: cavia, lac. For kx ater Suppiv& ln*ection[Wells: In addition to sending the form to
the address(es) above_ also submii dne copy of this font! within 30 days of
13b.Disinfectio!3 Amount: -6423 completion of well construction to!the counry health department of the county
- \N here constructed.
Form GVi-1 North Carolina Department of Etw ironnictital OuaI6-])]]]star ofWater Re,p%ircc, Revised 2-22.2016