GW1-2021-00418_Well Construction - GW1_20211206

WELL CONSTRUCTION RECORD(GW=1) For Internal Use Only:
1.Well Contractors Information:
Well Contractor Name FROM TO DESCRD!TION
1 �il' C4 '� Merl c e — Z o .
ao9S P
NC Well Contractor Certification Number �(
MGM TODIAMETER IMCICKESS MATERIAL
Company Name /^y C� fL 1 f.L �j. �° 1a� .Q,
HE
2.Well Construction Permit#:
0 Q ✓ ` FROM TO DIAMETER TRICICNESS MATERIAL
List all applicable well construction permits(Le.VIC,County,State.Variance,etc.) in.
3.Well Use(check well use): tt. ft in.
tGeothermal
r Supply Well: FROM TO DIAMETER SLOT SEW THICKNESS MATERIAL
Agricultural [3Mumicipal/Public EG it io
(Heating/Cooling Supply) esidential Water Supply(single) ft. tt
ustrial/Commercial Residential Water Supply(shared) Am on KIM
ion FROM TO ri 14ATERIAL EMPLACEMENT METHOD AMODNT
Non-Water Supply Well: a0 % a� ,7 e4'Gfie 1 b t)" S PSo 1�i
Monitoring _ Recovery ft. ft.
Injection Well: on0�l6 G
ft ft ;
Aquifer Recharge Groundwater Remediation
Aquifer Storage.and Recovery C)Saltnity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft ft.
Experimental Technology DSubsidence Control fL it.
Geothermal(Closed Loop) [3Tracer
Geothermal Coolin Return Other lam under#21 Remarks FROM TO DESCRyinioN cobs hardn solVrock We,Vain the%etc.
p n 6a ft. b-u..C�
a.Date Well(s)Completed: 0 Well ID# b,,� R• 14-0
5a.Well Location: )`�1-0 fL 4 c, 2 r'1
ft d0 G� —
Tob�aS Qo�L ft ;"fe
Facility/Owner Name Facility ID#(if licable)' ft l �.,Q)t
G e- o,n I OL ur� $ S he V� 1 e PC ft tt
PEG 6
r dd Co y and Zipr � a� I I '(� 5
ft. ft.K.t1 .D � vv��tr-� NERIMM
County Parcel Idealificetion No..(PIN) VEMMADOM PUnCESSI.r.i0L_
5b.Latitude and longitude in degremhadantes/seconds or decimal degrees:
(if well field,one let/long is sufficient) / 22.Certification:
N g a ° 36 � as $ � W 0
� � 3 a opy).,
6.h(am)the wells) Permanent or OTemporary Sigmtum of Certified well Contractor
By signing this form,I hereby ce*that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or, No with 75A NCAC 02C.0100 or IJA NCAC 01C.0200 well Construction Standards and chat a
If this is a repats,fill out known well conslructivn it fomwtion and explahr 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.
drilled: SU-BAHTTAL INSTRUCTIONS
9.Total well depth below land surface: a 0 5- ( ) . 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths lfdi&-a(example-3©200'and 2@100) c nstrtiction to the following:
10.Static water level below bop of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifvmter level is above casing use"+ 1617 Mail Service Center,.Raleigh,NC 27699.1617
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: d`'"� construction to the following:
(i e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) d1 Method of test: ' 24c.For Water SaDDIv&Infection 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: Ari L� Amowt: o 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
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