GW1-2021-07538_Well Construction - GW1_20210903

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WELL CONSTRUCTION RECORD QW-1) For Internal Use Only:
1.Well Contractor Information: 7
��k.1 C/!�t'lrl 14.-WATER'ZONES i
FROM TO DESCRnVn0N
Well Contractor Name
302,q
conft. ,
NC Well Contractor Certification Number Id.OUTWCASIDIG rmul -1aseA weDa O 'MER Eceble
FROM TO DIAMETER THICKNESti MATERIAL
0 6 in.
Company Name �) 16.INNEER CASIN OR T[IBING: thermal closed-loop)
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2.Well Construction Permit A �" u� [/ FROM TO I DIAMBTBR I THICKNESS MATERIAL
List all applicable well construction permits(i e.UIC,County,State,Variance,etc.) ft. it. I In.
3.Well Use(check well use): ft. ft.
Water Supply Well: FROM TO D �, sLOT SIM I TMCKNass I MATERM
Agricultural 13M cipal/Public p ft. ft. im
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) g, g.
Industrial/Commercial Residential Water Supply(shared) IS;GROUT i
Irri lion FROM TO MATERIAL ENN)PLLA METHOD tic AMOUNT
` Non-Water Supply Well: 6 ft ft.
_ Monitoring _ Recovery ft. ft.
Injection Well: ft. fL
_. Aquifer Recharge 1313roundwaterRemediation
D.SAND/GRAVEL:PACR f 'Ileabk
Aquifer Storage and Recovery 13Salinity Barrier FROM To I MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft ft
Experimental Technology OSubsidence Control fL ft.
Geothermal(Closed Loop) Tracer 20:DRII.LING LOG attach additional shei:ts if
FROM TO 1(leothermal Heatin Coolin Return) Other Iain under#21 Remarks DESCRn�TION or 6rudn soiVioek eta
zft.
tL �
4.Date Well(s)Completed:.7_Zg •2men Ew ft'
Se.WellLocation:n ft.
/►Q/�L�+ I�.lA,-N
Facility/Owner Name Facility MO(if applicable) ft ft.
Physical Address,City,and Zip
2756 ft. tt. 4
Ct�'f&m A 1� [ a1.ReMAREs
County Pareel identification No.(PIN) PC
5b.Latitude and longitude in degrees/urinates/seconds or decimal degrees:
(if well field,one hit/long is sufficient) 22.Certiflca'
bZ 2 1 W
,.�
6.Is(are)the well(s)Qfermaneut or DTemporary rgnature '' ed well ContrMo Date
� By signing this form,I hereby certify that the wells)was(were)constructed in accordwce
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7.Is this a repair to 80 OUting well: OYes Or 410 with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If dds is a repair,fill out known well construction Information and explain the nature of the ropy of this record has been provided to the well 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 rosy also attach additional pages if necessary.
drilled: Q SUBMITTAL INSTRIIGTION3
9.Total well depth below land surface: J O� (R-) 24a,For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dent(example•3@200'and 2®100)' construction to the following:
10.Static water level below top of casing: �� e (tt.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+". 1617 Mall 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 form within 30 days of completion of well
12.Well construction method: construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2769XI636
13a.Yield(gpm) Method of test 4CLJ^ a VW For Water Supply_&"IM11lon Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: Ow�e,tb completion of well construction to the county health department of the county
where constmeted.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016