GW1-2021-07452_Well Construction - GW1_20211006

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: �� _ -71'1
'14-WATER ZbNES;'
Well Contractor Name O OM TO DESCRIPTION
fL n A
3yq 1 -�+ o�� r�e�y`�� rL a o ft
NC Well Contractor Certification Number
1� q F, � FROM TO DIAMETER °ORLIXER'Ifa"OEable
np11TER:CASIIVG;:-fdYmitlk-cased wells
A W 1 60 l e_ (p e-11 � R.. ft. in. THICVNSS MATERIAL
Company Name a (p(2.Well Construction Permit#:_&t /
`, INNERCASING OR,TUBIIVG Crothermal hlaised'loo ;.. '
q_ Q-I9-350 t� "16:d FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) fI- rt.
3.Well Use(check well use): ft ft in.
Water Supply Well: 17.:SCRE>N
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
�Agricultural OMunicipaUPublic 0 ft. rt h,
Geothermal(Heating/Cooling Supply) residential Water Supply(single) (t I ft. in.
JndttStrial/Commercial DResidential Water Supply(shared)
a&ORO[Tf r,
Irri ation FROM TO MATERIAL ! EMPLA MENT METHOD&AMOUNT
Non-Water Supply Well: ft. (26 CL
Monitoring Recovery ft Ct
Wu r
Injection Well:
R Aquifer Recharge QGroundwater Remediation ft.
,J9r AND/GRAV'ELPACK if60blicablpA Aquifer Storage and Recovery ry Salinity Barrier
FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test oStonnwater Drainage ft• ft
Experimental Technology oSubsidence Control ft. ft.
[DGeotliernal(Closed Loop) OTracer 2U RIT Li1vTo QG'attachsadelitlonalsHe ts,ifnek a'
Geothenmal(Heating/Cooling Return Other(explain under#21 Remarks IFRO DESCRIPTION(color,hmdn soNrock type,grain size eta
ft fL ^rib
4.Date Well(s)Completed: Well ID# ft n. I Vc l
5a.Well
Location: tt fL ram^�•
P U T r-y 4mes ft ft
Facility/Owner Name Facility ID#(if applicable) ft. ft
502(3 d J(�IIrS Dr. �G/e!
yA Nc a Z��� M ft
Physical Address,
City,and Zip ft CL
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one I Ill
Jon s sufficient) 22.Certification*
9�-152 N v' `� 1 0 lU v W
-5 -2�-Z /
6.Is(are)the well(s)[Permanent or DTemporary Si on trot Date
By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or P<0 with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill our known well construction information and explain the nature of the copy of this record has been provided to the ivell'owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: f
`/ SUBMITTAL INSTRUCTIONS
?.Total well depth below land surface: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple iveGs list all depths if different(example-3Q200'and 2Q100)
construction to the following:
10.Static water level below lop of casing: A) Division of Water Resources Information Processing Unit,
1/water level is above casing,use"+" r
6 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: '(in) 24b.For Iniection Wells: In addition to i ending the form to the address in 24a
y
12.Well construction method: 1�G�e,ry above,also submit one copy of this form'within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following: k
FOR WATER SUPPLY WELLS ONLY Division of Water Resources,Underground Injection Control Program,
2 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) J Method of test: U L4/ 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this forth within 30 days of
j 13b.Disinfection type: 1 ` Amount: /7 completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-20I6