GW1-2021-00673_Well Construction - GW1_20211222

:t nnt��wet
WELL CONSTRUCTION RECORD(QW-D For Intemal Use Only:
1.Well Contractorinformation:
14.WATER ZOMS
FROM TO DESCRIPTION
WoUCoatractorNaate 30z / �" /70 � ', ''�
tl. �
NC Well C/o-ntr'eutorC=tMostimNumber ? l9. Cffm rmum-ca eawe RuraR Ueable
ZCl�O'nS L.A'1L. FROM To Drae1STER TlucxNass MATERrA1.
Company Name �- 0J V.
16.INNER OR TUBING thermal close"00111
2.Well Construction Permit A PROM TO DlAhtff t THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Co",State,Farlmlce,etc.) ft. ft in.
3.Well Use(check well use): R. 8. 74
ie.
Pater Supply well-. 37:SCRIM :
PROM TO DIAMErM scarsrT TmCMrsss MATErttAL
0Agricultural E314unicipalftbiic t) fL ft. in.
Geothermal(Heating/Cooting Supply) residential Waw Supply(single) ft, g, im
Industrial/Commercial Residential Water Supply(shared) I&GROUT
- Irrigation FROM TO MATERNAL EMPUCEMEWMEMOD&AMOUNT
Non-Water Sappy Well: ft-
_ go
ft- 3
Monitoring _ Recovery & t i
jar
1 weetion Well: r
_,Aquifer Recharge
DCrmundwa6ot Remaliation ft. ft.
19:9AND/GRAVEL.PACK a ite"
Aquifer Storage and Recovery Salinity Barrier FROM TO MATFdtrAT FM1"CHMMr METHOD
Aquifer Test DStormwater Drainage ft. R•
Experimental Technology DSubsideace Control ft. ft.
Geothermal(Closed hoop) Tracer -21 D LiNG'LOG atfech addito al sheets N
Geothermal eatin Coolin Return Other( lain under#21 Remarks FROM TO DESCRIPTION eolm sotlhodc
ft. fL bijef r r
4.Date Well(s)Completed:►- •7 Well W# ft. L&PL r
So.��Weell Lo atiioon: ft
ft-tt'a
V/G //4�Sdri ft. tt. fir_ ' "A r..
Facility/Owner Name Facility lD#(ifopplicable)
70 l kcP3t.. /am, �a.us�+^ca ►'LL ft, tz. z 2
physical Address,aty,and Zip .� rL
21.RBMARSS
County Parcel Identification.No.(PM
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Wong is sufficient) 22.C lificati n:
360:'S0•°I10!Q N 7g'Dl(o't8• 27 .1'72�w
6.Is(ate)the weD(s) r mneut or Memporarp IS patu A of Car tiSed Well or Dare
By signing this form,l hereby cr 16 that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or yVTo with 15ANCAC 02C.0100 or 15ANCAC 02C 11200 Well Construction Standards and that a
If this is a repair,fill out known well construcdan Information and expiain the Mare of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back offtform. 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:
9.Total well depth below hand surface: R ( ) 24a.For All wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(esample-3@200'and 2@1001 construction to the following:
10.Static water level below to of easing r
p casing �� (ft.) Division of water Resources,Information Processing Urdt,
If water level is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
ii.Borehole diameter: 24b.For Iniectio Wens: 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 past,ete.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resonrces.Underground I� Control
eoHon Conol Program,
1636 Mail Service Center,Raleigh,NC 276MI636
13a.Yield(gpm) Method of test: 1314DW^ ` jVc.For water Snoft&Injection wells: In addition to sending the form to
p the address(es) above, also submit one copy of this form within 30 days of
13b.Minfeetion type: Amount: IS O 16e vl f-CAP completion of well construction to the county health department of the county
where consWcxed.
Form GW-1 North Carolina Depaemrent of Environmental Quality-Division of Water Resources Revised 2 22 2016