GW1-2021-07776_Well Construction - GW1_20211116

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: a
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1.WJ Contractor Information:
Well Contractor Name FROM TO DESCRIPTION
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NC Well Contractor Certification Number 15::ODTER'CASING'for multi-cased+wells fL1L ER"± bcable
/ FROM TO DIAMETER THICKNESS MATERIALwel {
/ ( ft 11. % in. WI P_
Company Na (O 16-1NNE1CCASING ORTIIBING{eothermal closed-loo ,,
2.Well Construction Permit#: FROM TO I DIAMETER I THICIOWSS I MATERIAL.
List all applicable well construction permits f.e.UIC.County,State,Variance,etc.) fL ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: ;i7.'SGREEN'. ;a ,. _ •- ", .
PFROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Muni "paVPublic ft in.Geothermal(Heating/Cooling Supply) _ esidentiai Water Supply(single) ft. in.Industrial/Commcrcial Residential Water Supply(shared) IITIrri ation TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. v ft. u�
Monitoring Recovery ft. fL
Injection Well: ft. ft.
i__Aquifer Recharge QGroundwater Remediation
i`19.;SAND/GRAVEL'RACIC'rf -:a :.livable - '
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test EIStormwater Drainage ft. fL
Experimental Technology Subsidence Control ft. ft.
i Geothermal(Closed Loop) Tracer -`20:DRMLING LOG attach-additional sheets.if neeessa
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks FROM To DESCRIPTION color 6erdaess soiUrock e, In sae etc.
4.Date Well(s)Completed: �02 Well ID# l L/Q ft. -72(O ft.
5a.Well Location: ft. ft
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J&/-/)" f/ ,C ft. ft.
Facility/OwncrName Facility lD#(if applicable) ft. ft.
- XS �CG�+iG y l/� �� ft. ft. _
Physical Address,City,and Zip
O >j 5/ 21`REMARKS .
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County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification'
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2
6.Is(are)the weff(s)el ermanent or OTemporary Signa o e &Well ctor Date
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or 090 with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy 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:
8.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.
filed' t SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: '00 (R) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'.and 2@100� construction to the following:
10.Static water level below top of casing: ro
I (M) Division of Water Resources,Information Processing Unit,
If water level is above caring,use'+" 1617 Mail Service'Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the fora to the address in 24a
`1 above, also submit one copy of(this form within 30 days of completion of well
12.Well construction method: Q• X670r- construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) _ Method of test: A.,- 24c.For Water Supply&Ini I tion 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: 14.- 1-t Amount: I�11 ot; completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016