GW1-2021-02291_Well Construction - GW1_20210722

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WELL CONSTRUCTION REC• D(GW"1) For Internal Use'On'
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1.Well Contractor Informs'on•
14.WATER ZONES
We R t TO .DES 1l'TION -
(/Qnh err n% tt.
� ft. ft.
NC Well unljactor Cert tion Number 15.OUTER CASING for multi-cased wells OR LINER Won likable
FROM I T DWigM I THIChNESS _ 31AX4MIAL -
ft tL in.
Company Name 16.INNER IN ORTUBI G thermal closed-loop)
2.Well Construction Permit#: FRo?I TO [IMMETER I THICKNESS MATERIAL.
List all applicable imll construction permits(i.e.VIC,County.Stare.Variance.e(c.) R It. to
3.Well Use(check well use): R' IL in
i
Water Supply Well: 17.SCREEN:
PPY FROM TO I DIA%iETER I SLOTSIZE I THICKNESS I INIATERFAL
Agricultural []Municipal/Public tt. z1ft
lo• C
Geothermal(Heating/Cooling Supply) esidenttal Water Supply(single) R R, lrj.
Industrial/Commercial esidential Water Supply(shared) .18.GROUT }
It1i tiorl FROM TO MATERIAL E LACEM TMETHOD&AMOUNT
Non-Water Supply Well:
Monitoring Recovery R• D•
Injection Well: g g,
Aquifer Recharge []Groundwater Remediation 19.SAND/GRAVEL PACK f applicable)
Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL §aPIACEM OD
Aquifer Test []Stonnx•ater Drainage t
Experimental Technology []Subsidence Control
Geothermal(Closed Loop) []Tracer 20.DRILLING LOG(attach additional sheets tf necessa001.
FROM TO DE_SCRIPTIO\(color.hardness.so rock h e.•sni sire.ere.
Geothenal(Heating/Coolin Return) Other(explain tinder#2t Remarls) h
I
4.Date Well(s)Completed: Well IDIr
• it. j
Sa We Locatto
ft. ft.
Factiity Owner Name IV Facility iD#(ifapplicabie)
nd Zi
Physical ,C' .,ap
+g 21.REMARK5 i
►L"' K r jJUL ow i:d •
? Couniy q; Parcel identification No..(PIN) ^
t r t Processing (Jill)
5b.Latitude and 1041tude in d'egrees/minuteslseconds or decimal degrees: f ;' i d`r, vE ,
i irwe held,one lat/long is suflleteM), x j� �) t 22.Ce ft Cation:
.a�[�■uj{�f�'' / ' /.N - W
Signalure o if eltContractor Date
6.Is(are)the well(s)
rmancut or.[]Temporary /
By signing t is form.i hereby certify that the xell(s)was(were)constntcted.in accord f
pith NSA NCAC 02C.0100 or I5A NCAC 02C 02U0 Nell Construction Standards and that a
r 7.Is this a repair to n existing well- []Yes or,
.�.
Ifthis is a repair,fill out knoim sell construction infom.ion d erplain din m nae of the cops'of this record has been provide toirhe ue11`Qnan.
repair under t121 renratia section or on the bath ofthis form- 23.Site diagram or additional Nell details:
You may.use the back of this page to provide additional well site details or well
8..1 or CcoprobclDPT oriClosed-Loop Geothermal Netts having the same
construction details. You may a
construction,only 1 GW-t is needed. Indicate TOTAL NUMBER of wells lsoattach additional pages ifnecessary.
drilled- SUBMITTAlt3N fRU 1 S
9.Total well depth below land surface: �/ (ft) 24a. For All i Wells�is form within 30 days of completion of well
par multiple evils list all depths il'd(ftrent(example-3 ct�00'and I r/"r I UU) conspvction to the following:
10.Static water level below top of casing:_Z 6 � (ft.) Division of Water Resources,Information Processing Unit,
If under level is above cnNng,use -"� 1617 Mail Service Center,Raleigh,NC 27699-1617.
� 6 ,
11.Borehole diameter 9 24b.For luiection Wells: in addition to sending the form to the address in 24a
above;also submit one copy of this fonn within 30 days of completion of well
12.Well construction method: &&4 construction to the following:
_ (i.e.auger,rotary.cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
C'OR WATER SUPPLY WELLS ONLY: + 1636 Mail Service Center,Raleigh,NC 27699-1636
T
13a.Yield(gpm) U Method of test:, 6tf/�i 24c.For Water Suaniv&Infection Wells: In addition to sending the form to
Q the address(es) above, also submit one copy of this form within 30 days of
F dab.Disinfection type: Amount• 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 2-23-2016