GW1-2021-07414_Well Construction - GW1_20210921

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
FROM To DFSCRIPTION' i
Well Contractor Na,nc
0 I'L I OW
oci c
cl;� 110
ILK> 230 1 6L-)
NC Well Contractor Cenification Numbei C, IS.OUTER CASING(for T!L1tci,-dw wells O_B L I (if ap1liEbie
FROM TO DIAMETER TN )
MATERIAL
ALo� r) ft. ft. in.
Compao� Name P�
16.INNER CASING OR TUBING eother al closed-loop)
2.Well Construction Permit 4: FROM TO I DIAMFTERi THICKNESS MATERIAL
1.1,1 pertivm fl,v, c/c, ft. ft. I&V zs, !,in" I 21 P VC
ft, !in.
3.Well Use(check well use):
Water Supply NN ell: 17.SCREEN
FROM TO DIAMETER j SLOT 1IZF THICKNESS MATERIAL
Agricultural OMunicipaliPubtic ft. ft. in. 1:
Geothermal(lik. 1111L/Cooling Supply) OReseemial Water Supply(single) -
ft. ft.
lndustrial/Cor­;ncr,'.:l 04sidential Water Supply(shared) -18.GROUT
Irrivation FROM I TO MATERIAL E-31PLACENIENT METHOD&AMOLINT
Non-Water Sulanly NA ell:
c) P6 Lka_
Recovery ft. ft. I
CAA
Injection Well: ft I ft.
Aquifer Recha:_.e nGroundwater Rerriediation
19.SAN))/GRAVFL PACK(if applicable)
Aquifer Storaac and Recover\ [3Salinity Barrier FROM 1,0 1 MATERIA1 EMPLACEMENTNIETHOD
Aquifer Test Ostorm\%ater i)ramage ft,. ft.
Expermiental :Lcnno!og [3Subsidence Control
Geothormal(C:o,c Loop) OTracer 1 20.DRILLING LOG(attach additional,sheets if necessary)
Geothermal Return) [30ther(explain under#2) Remarks) FROM ft. ft.to DESCRIPTION(color,hardness.soiVrock rain size.etc.)
A
4.Date Well(s)(omplcted:3-1S_-'LV_ W,IIID#
5a.Well Locatin,i:
ft. ft.
Rplieffl. FcAA*_R
Facili,,\.ID46fapplicable)
C
ft.
)
Physical Address.Cil�.;t?0,Zip W-I q 7- ft. ft.
95 25*3 cito 3 1 S 21.RENIARKS
-
Count} Parcel Identification No.(PINT
5b.Latitude and ion,,irude in degrees/minutes/seconds or decimal degrees:
(if\Nell field.one la,lon.L�i,sutlieient7 72.Certifii anon:n.
Scl 11 15. 5934, 13-2-0 3 to' .11 ,o-7 23 35 NN ft_ -
6.Is(are)the weil(s) ermanent or ®Temporary e"SignatureofCcrtified Well Contractor Date
rgiil�
HV signnr,thi,fin-in,I herehl-ceritfl,(liar the weitt.q iva, liverei cumv!rucied in accorclance
7.Is this a reps;-to existing well: Wes or Q 'o mah 15A M'AC 02C.1;101ior 1iAA'CACO2C 020 Ifell and That a
111his 1"'irepair. ow i,,,//(wwriwiton mliwininion undexphim the nature nfthe enpr n1 lh;, been provided io rile wciloitner.
repair muter cz-fieni or on thr hwk,?1,1h1sfinw). 23.Site diagram or additional well details:
8.For Geoprobe:DPT or Closed-Loop Geothermal Wells having the same You ma\ ase the hack of this page io provide additional well site details or well
construction.on: 1 is needed. Indicate TOTAL NUM BER of wells construcuondetails. You may also attach additional pages if necessary.
drilled:
SUBMITTAL UNSTRUCTION'S
9.Total well depth neww land surface: 0? G5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
bnr construction to the fibilovving:
10.Static water:e-0 below top of casing: (ft.) Division of Water Resources.Information Processing Unit,
lf water level Isol", li,e 1617 Mail Service Center.Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
above.also submit one copy of This torn within 30 days of completion of well
12.Well constrza ziw-,method: Prdne=i uonstruci:-,:l to the,tbllovvina:
(i.e.augel%rotal".c:­Ic.direct push.cl, ; C4
Division of Water Resources,U fiderground Injection Control Program,
FOR NNATER i PHA WELL",ONLY: 1636 Mail Service("enter,Raleigh,NC 27699-1636
13a.Yield(,-Pm) a,5 Method of test:04/ Cbn/a inde.24c. For«ater Supply& Injection;Wells: In addition to sending the form to
the addrc�s(es) above. also SUbi-rift one coty of this form within 30 days of
13b.Disinfection=vu Amount: completion of well construction to,the county health department of the county
-h-constructed.
Form Gtc-f North Carolina Department of Environniernal Oualk -i)i\t,00n of Water Re-oarces Revised 2-22-2016