GW1-2021-00395_Well Construction - GW1_20211230

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WELL CONST'RUC'TION]r. ORID (GW-1) For lntemal Us y:
1.Well Contractor Information:
14.WAT R'ZO1vE�
FROM TU DESCRIPTIONN
Well Contra r c Name ft. ft.
�I33S ft.
NC Well Contractor Certification Number f5UUTERCASL�tGfot`innl[ie83ei7.vfellsOR'LINER':ifa ltcatile
F'RO\I 'I'O 1)IAYIE rF.R '1'H ICK\F;SS MATERIAL
r� ) , ham- rt. C0' in. SD 21 VC
Compare Namc t6.INNER CASING OR TURJNG.tgcothermal:closcd-too
2.Well Construction Permit#: ��� - � I�3 FROM ft. ft,'to DL4.NIETER in. THICKNESS M4TERIAL
List all applicable well construction permits It.e.VIC.Counm State.Varionce.er,
ft. ft. in.
3.Well Use(check well use):
17::SCREEN::::::
Water Supply Well: FROM I TO DIAMETER SLOTSTZE I THICKNESS MATERT..AL
Agricultural DMunicipal/Public twocu ft. R. in.
Geothermal(Heatine/Cooling Supply) oResi tial Water Supply(single) ft ft. in.
Tndustrial/Commercial IdResidential Water Supply(shared) 18:GROUT
turn ation FROM I'O MATERIAI. FNIPLACF:MFATAIF.THOD&ANIOUN-r
Non-Water Supply Well: _ ft. ft. ory _ `
Monitoring ORecoven ft. ft. %In"
"
u
Injection Well: ft. ft.
Aquifer Recharge DGround%Nater Remediation
19.. N0/GRAVEL P.ACK1i a`Nimble)
Aquifer Storage and Recovery Salinity Barrier FROM TO pLNTERI IL EMPL&CEINLNr METHOD
Aquifer Test DStonnwatcr Drainage
Experimental Technology [:3Subsidcnce Control ft. ft.
8Geothermal(Closed Loop) Tracer :20.DRILLING'LOG attach.additionalsheetsl if.mcessa;•:
FROM TO DESCRIPTION(color,hardness.sosUroek c ,n sin,ctd
Geothetrrtal(Heating/Cooling Return) Other(explain under#?I Remarks) fL � fr. C
4.Date Well(s)Completed: 01-2 ".1 Well ID# 35, It. L-0 ft.
5a.Well Location: 109 700 h
Facility/Owner Name- Facility 1D4(il'applicable)
7 h
9s- / t /1- !A.) Lan 1 _ 0_ H 1 I
L1—g� —IY/ � Q"J QSV)A
Physical Address,City,an Zip ft. Ct
CIS 21`REYIi1RKS
County Parcel Identification No.(PIN) �lt('r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) Q 22.Ce 'Ication
I <�:?__ 9 -/. /Y
6.Is(are)the well(s) rmanent or Temporary $ignature of Ceru ed V el Contractor Da e
Br signing this/brat,r herchr certih,that the,vell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or �o teidt/i'4.V(*. C O'C'.n100 or lSA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is re lair.ell out Anown well consrruction infonnation and explain the nature ofthe co/n•ofthis record has been provided to the sur1l owner.
repair under 421 remarks sm-fion or on the buck of dds finrm.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells hmring 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: SUBMITTAL L-NSTRUCT16NS
9.Total well depth below-land surface: 70 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For mulriple well,list all depths ifditcrew tesunnple-3i 20O)'a'nnd?(ra;100') construction to the following:
10.Static water level below top of casing: NVIJ (ft.) Division of Water Resources.information Processing Unit,
ff%vler level is above easing,use•'+" 1617 Mail Service Center.Raleigh.NC 2 7 699-1 6 1 7
11.Borehole diameter: (in.) 24b. For Infection 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: I y n LLVI I construction to the following: 1
(i.e.auger,rotary,cable,direct push,etc.) '
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: n 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 Method of test: f'11 r 24c.For Water Supply& 1 M iei:tion Wells: In addition to sending the form to
/1" ' the address(es) above. also submit one copy of this form within 30 days of
136.Disinfection type Amount: W completion of well constivetion 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