GW1-2021-07374_Well Construction - GW1_20210921

MEMMME
WELL CONSTRUCTION RECORD(GW-li For Immal Use OW.
1.Well Contractor information:
I fo g J A c e b S 14 WATER-,ZQN6S
/� J ( FRaM TO DS5CRUMM
Well Contractor Name
� L9� it fL
NC Welt Cormactaz Certification Numbs` c,;tC1 'ODTBR:CASlNG tori3► ed tvdb
1 fL 3D ,
ft )
t7 / j�C'3� ..a� FRetffi TO DIA6�i78 t. THIC>OITSS MATISRrAr
% 602
ft m /
Companyl+iante `j �113 �-y
-
2.Well Constracdon Permit# FROM TO DUMTFR TffiCM M MATI3RiAi.
Gist all applicable well eonsttaetfon permits(Le.111C.County,State,Variance,eta) ft f' in.
3.Well Use(check well use): it. R in.
Water Supply Well: 27.SQtEEl!I. r° ;
FROM I TO I DIADWER I SLOT SI E I MATERML
cultural paliPubiic 0 fl, ft is
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) yb
hidostriaUCommercial [31kesidential Water Supply(shared)
ltri on FROM I TO MAT€RM FdliFirlCIIU ODAM1011 T
Non-water supply well:
Monitoring Recovery ft. �
Injection Well:
ft:Aquifer Recharge OGroundwater Reme diation �
quifer Stomp
and Recovery C)Salimly Barrier FROM TO M42Y$IAL i -F2K'LAC IN1'MELHOD
oifer Test 13Stormwater Drainage R fL
Experimental Technology 13Subsidemce Control fw R
Geothermal(Closed loop) [3TMcer .20:=DRFL I.n+tG3.OG saaeb addittomdai eetdif
Gexrtheamai Cooling Return tJtlier lain under#21 Remadcs FRom To DESOWnON coley 6edam,-W--k
C) & G SGr'(
4.Dal Wells)Completed- Well ID# —ft. R C G a
Sa-Well Location it. 3 fk r5 ;_ L
� CD ( ,Y\ � Ott �_ ft: t
Fscil4/0wner Name Facility ID#(i£ te) R fi:
Plrysical Address.City,and Zap a
2LXEMARKS. ::-
C—ty Parcel Identification No.(PIN) - 6 ein r;ill e' ,,,5 'e
5b.Latitude and loogitade in degreWminutes/seconds or decimal degrees:
(ifwell field,use lavim is sufHoi m)
22.Certification l f r
6.Is(are)the wen(s) rmsnent or Tem ra S' c po ry tgnstme ofC 'tied Well Connactor
7-Is this a repair to an existing wen: Oyes or E)No 8'srgnutg this form,1 he-AY ,M yy that the wells)was(were)eonrtri:W in accordance
1f this is a-pair,fill om known well consavctlon infotnrallon and explain the nature of the roPY phis record has been prav>ded tto the we!/OowneW
dt Constriction SYandaIds and that a
trpair—-421-marts section or an the back ofihis f",
23.Site diagram or additional well details:
8.For GeoprobeNPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or welt
drilled:construction,only 1 GW I is needed. Indicate TOTAL NUMBER of wells
dulled: construction details. You may also attach additional pages if necessary.
�� SUBMITTAL nysrttrrr-rrnrve
9-Total well depth below land surface: q
For multiple wells list all depths ifdljjitrent(example.3(a)200'and 2@100) ( ) 241L or Wells: Submit this form within 30 days of completion of well
construction to the following
10-Static water level below imp of castag-
lf {fit.}—W level is above aartng use"+; Division of Water Resources,Information Processing Unit,
\(ff 1617 Mail Service Cent ir,Raleigh,NC 27699-1617
11-Borebole diameter: (in.}
24b>F9r Ynlecttan wars: In additionito sending the form to the address in 24s
12.Well construction method: Ro 1 Pi n%-/ above,also submit one copy Of this form,within 30 days of completion Of well
0A eager,may.cable,direct push,etc} construction to the following:
E13b.Dbluffttion
ER SUPPLY WELLS ONLY: Division of Water Resources,Underground Lajection Control Program,
Rpm) S 1636 Man Service Centel,Ralelgh,NC 27699-1636
Method of test: ' U i/`' 24c,Par Water Sunaiv&Inieetion WeI1s: In addition to sending the form to
type: Amount: the addresses) above, also submit one copy of this form within 30 days of
completion of well construction to the`county health department of the courty
where constructed.
Foma GW-I North Camlina
IV8moem of Environmental Q_Iity-Division of Water Resmunes Revised 2-22-2016