GW1-2021-07415_Well Construction - GW1_20210921

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor information!
14.WATER ZONES
,
Well Contractor Naine FROM TO DESCRIPTION
6,
Lfc)9 S--R
NC Well Contractor Certification\unibci-
15.OUTER CASING(for it AL
multi
'%"� 0 LINER
FROM TO T!LD_1A'121S1`TE_.l"S�r_!TN_1I1L11R
Compan} Name 16.INNER CASING OR TUBING eotl i let al closed-loop)
2.Well Construction Permit 14: FROM i TO W's ESS J MATERIAL
Ltct ah'appli, trin-tto it perlint,ii.e. ("intin i.in ite. EirrtoucC.rtc.r C) ft. i
I ft- 11.-isin.- In, 1.5 ve z i Vc-
1
3.Well Use(check"ell use): ft. ft. I
17.SCREEN
Water Supply NN ell: FROM TO DLAMETER •SLOT SIZE THICKNESS I MATERIAL
Agricultural 13MqpeipaltPublic ft. ft. in.
Geothermal(Kc4tinpiCocifing Supply) 1;31:esidcntial Water Supply(single)
f. in.
Inclustrial/Corr.ner,ii.<l 0 Residential Water Supply(shared) I-I&GROUT
Irrigation FROM I TO MATERIAL �.MIILAC�ENIrNnr METHOD&AMOUNT
Non-Water Supply Well: fr. ft. F-0 L-ky-
:1monnoring [3 Recovery f!. ft.
Injection Well: cv�'1P
ft- l ft.
Aquifer Recha;_­, ®Groundwater Remediation -
19.SANDIGRAVEL PACK(ill'applicadde)
Aquifer Storauv and Recover\, rlSafinity Barrier FROM I TO MATERIAI" I EMPLACEMENT METHOD
Aquifer Test nstorm\yatcr[)rainage
Experimental [3Subsidence Control
Geothermal 1-oop) [3Traccr 20.DRILLING LOG(ana h additional sheets if necessary)
FROVI TO DESCRIPTION(color.hardness.soil/rock typ-,gruin size.etc.)
Geothermal(W:!::n_',Coolmg Return) r3Other(explain under 921 Remarks) i ft, ft. C.
4.Date Well(s)Compieted:.J.- 1- 2 t Well ID# 6 16C ft' CAV V\t V--
5a.Well Locati-1:
RtAck
Facility�Owleer Nan�c Facilky ID4(il'applicable)
ft.
Physical Address.Cii.�.;,nO.Zip V 2 ft.
21.REMARKS
14-e.jqcA_Avs*)a 14X10&Z_794J- - i
Count Parcel Identification NO.(PIN!
5b.Latitude ana ioii;,itude in degrees/minutes/seconds or decimal degrees.
(ifwell field,one k,,lont.,isufficicno 22.Certification:
AqZ2q6 I.Lo 21, 01 r,p Z-1 W
6.Is(are)the wvills)P�'Plrnianent or Temporary minim oi'Cenified Well Contractor Date
Ci' S�fl
tSr
ligning i;u,iorm, I herebY ce,It&that th,•iiellt%)ira, ficere)constnxted in accordance
7. Is this a repat.-to:m existing well: [3yes or ;Vo 'inh 'i'4AC.-It 02C.0101)or15.4 AVAC 02C.02hil Well sialidurds rind that a
�"� ;�Ie ,I,it Mtbrillillil 111 411111,.flare the;111111re 00he rapt
repuir umfer 21 orwithe h,,,,k eil'this ffirin.
23.Site diagram or additional well details:
8.For GeoprobvIDPT or Closed-Loop Geothermal Wells having the same You ma% ose the back of this pace ito provide additional xvell site details or well
construction.on!, 1 (',0,-I is needed. Indicate'TOTAI.NUMBER ofkvells constrUCituo details. You may also attach additional pages ifnecessary.
driiled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: E0.5 (ft-) 214a. For All Wells: Submit this{form within 30 days of completion of%veil
Formi'lliple constrUCtiOn to the hollowing'
10.Static water v­e°below top ofeasing.*_ (ft.) Division of Water Resou i rces,Information Processing Unit,
161,wer level"101� 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24h. For iniection NVells: In addition to sending the form to the address in 24a
above, aiso submit one cope of this fibrin within 30 days of completion of well
conStrUCi:.1t1 10 the f0Il0%Vin,1:
ox-111gel..
Division of Water Resources,Underground Injection Control Program,
FOR 1A ATER Si. WELLS ONLY: 1636 Mail Service C enter,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 Method of test:qkl. CAnVA* JL_ 24c. For Water Supply& I niection"Wells' In addition to sending the form to
the address(cs) above. also SlIbinit 6ne cony of this font ivithin 30 days of
13b.Disinfection Mlc'y;eam. Amount: 62jos 'oniplellon of well construction t'the county health department of the county
% I I
-1.c.,constructed. i
Fonn Gk\'-1 North Carolina Department of Envimmicnial Qualin-Di%ision of Water Rcsaarcc,' Remed 2-22.2016