GW1-2021-00393_Well Construction - GW1_20211230

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1. 1 Contractor Information:
4W 0 , �/) �a l[r�S 14 RATCR'ZOTiES 111 D�✓1v
FROM I TO I DESCRIPTION'
Nell Cont�r Name ft. fr.
r
ft. ft.
NCU^ell Contractor Certification Number 15::OUTERCASI1*tG farututd-cased"wells OR:LINER, ttcs6le
_ FRONI .1'O DI NIFITA 'THICKNESS MATERIAL
/bf t r, t Q., ft. ft. in. SDPi 2/ PUC
Company Name 16.IYNERGA'INGORTLIBING ^cothermalctosed400
f/ZZ l ��/ FRONT TO DIAMETER TBICKNESS NLkTERLAL
2.Well Construction Permit#:
in.
List all applicable null construction permits ti.e.CIC.Count'.State.Yuriunce.e1c.)
fL R•
ft. Ct. in.
3.Well Use(check well use):
17:>SCREEN-^z
Water Supply Well: FRONT TO I DIAMETER I SLOT SIZE I THICKNESS MATERIAL
Agricultural ON4111 al/Public fit., ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single)
Industrial'Commercial Residential Water Supply I•(shared)
18:'GROUT
ltrl ation F'RONI 1'O NIATERIAL F.NIPI.ACFMF.NTNIF.THOO&ANIOUN'I'
Nun-Water supply Well:
-
Monitoring ORecovery ft. D
Injection Well: ft. fr. 1
Aquifer Recharge Groundwater Remediation e
19<iS�1ND/GF2A;YEL.PAC3i{tCs, iicslble) :'
Aquifer Storage and Recovery Salinity Barrier FROM[ I To D[ATERI 1L EMPLILCEN[ENT METHOD
Aquifer Test [:1Stonnwater Drainage ft. fr.
Experimental Technology OSubsidcnce Control
Geothermal(Closed Loop) Tracer :20 DRILLING LOG'attach aaditivaal iheetsi€necessa
FROM TO DESCRIPTIONrnlor hnrdncss,smUrod: c in size,Na)
Geothermal(Heating/Cooling Return) Other(explain under :31 Remarks) D it
Zo ft. �a
4.Date Well(s)Completed:'2 1 Well 1Dft l� ft.
ft.
Well Location:
Facility/Owner Name Facility iD:(ifapplicable) DEF
ft.
ft. ft.
33 l�s V�Vej
� ����1�
Ph sisal Address,City,and Zip ft.
21
a. 't
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
_ I
(ifwell field,one lat/long is sufficient) 22.Cc ICahO f
n 1.057 N 0233 H7
6.Is(are)the well(s)OPermanent or QTemporarr' 4St�--, f a cl ontraclor Dale
Br signing Ihi.c form./herchv cerriti,that the ivetl(s)rvmv(ivcrcl constructed in accordance
7.Is this a repair to an existing well: [3Yes or o with l i.4 NV.4C 0-1C.LIRA)or 15.4 NCAC 02C.(1201)Nell Consu•uction Statdards attd that a
if this is a repair.fill out Anowt well constntction information and explain the nature of the soli-of this record has been provided to the it-ell owner.
repair under 421 remarkv section or on the buck elf this juah.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells haying 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 ifnecessary.
drilled: 01 SUBMITTAL INSTRUCTIONS
9.Total well depth below'laud surface: I© (ft.) 24a. For All Wells: Submir;this form within 30 days of completion of well
For multiple wells list all depths itdiiJ eent(example-3-*200'(Ind (d:/(fir) construction to the fol lowin_:
10.Static water level below top of casing: Nl/ (ft.) Division of Water Resources.information Processing Unit,
/!"xweer level is above casing.use"_.. 1617 Mail Service Center.Raleigh,NC 27 69 9-1 6 1 7
11.Borehole diameter: v (in. 24b. For Iniection Wells: lnladdition to sending the form to the address in 24a
��,K above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: /� construction to the following:
(i.e.auger,rotary,cable,direct push,etc.
Division of Water Resourees,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Servi i ce Center,Raleigh,NC 27699-1636
13a.Yield(gpni) Method of test: 24c.For Water Supply& Iniection 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: U completion of well construction to the county health department of the county
where constructed.
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016