GW1-2021-02406_Well Construction - GW1_20210527

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor information:
14.WATER ZONES
FROM I DESCRIPTION'
Well Contractor Namc fL ft. I *n(I&W
Lfoqe� - ft11z)LAJ
NC'Nell Contractor(mitigation Number 15.OUTER CASING(for multi-c LINER
_ER'i'applicable
nc- ft. )
FROM To DIAM TTETER ".gs" I MATERIAL
i
Company Name 16.INNER CASING OR TU !�,.%G �o 11,e r al closed-loop)
2.Well Construction Permit 4: 90 0 0 CX) FROM i TO I THICKNESS MATERIAL
boa//applicable,ch,,.-,true fla It perlint"I I.e, "A", ft. in,
3.Well Use(check Weil use): ft. ft. !in.
Hater Supply N't ell: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3mu ipal/Public ft. ft. in.
,Coo Supph Geothermal I Hoaltn2hna l Vesaid,ntial Water Supply(single)
- - f- ft. in.
Industrial/Cor-.:ne.-,'z.,! E)Residential Water Supply(shared) IS.GROUT
Irripation FROM I TO —MATERIAL• EMPLACEMENT METHOD AMOtNT
Non-Water Supply Well: f- i C90 I,- lRe f i I-e- I 4?nL31Xz_
:1Monitoring Recovery I". ft'
Injection Well-
ft. i ft.
3Aquifer Recha:,_,e ®Groundwater Reiriediation
19.SANI)!CRAVFL PACK(if applicable)
Aquifer Storaa�and Recover [3Salimty Barrier I FROM To MATERIAL EMPLACEMENTmETHOD
Aquifer Test nStorm%%ater Drainage
Experimental-_,,nno!ogv rJSubsidence control
Geothermal(C:,,sc_'1.00p) nTracer 20.DRILLING LOG(attach additional sheets ifnecessary)
Geothermal RelL1,n) r3Other(explain under#21 Remarks) I I T 6 1 1)ESCRIPTIONI color.hardness.soil/rock qp�.timin size.etc.)
ft, I Cf ft. /6Ve_V_kLArCLg4
4.Date W q
Well(s)(ompleted: —621_c�( NA,'elllD#. ft. it 4-t-
ft, I R.
5a.Well Locati—i:
f,
ft.
ED Facilitv,OW4.M, e Fa(;ili',-,-ID4 f..,(ilapplicable) ft. RECEiV
0 60�,ftr C-t—caji< Ed ft.
Physical Address.Cit\.;md Zip ft. MAY 2 7 2021
21.RENIARKS
hlblnMibn Prucessing Unit
Count Parcel Winification No.WIN) MIR Sp
5b.Latitude one.iongitude in degrees/minutes/seconds or decimal degrees.
(if vell field,one is loii,_,i,sufficient}
:zq�zo 3V 13A.679C 22.Certification:
. #70(03,F "
6.Is(are)the writs) erma ne tit or [3Temporan- /01gnawre ofConified Well Comrac!or Data
1A G;j,fi,rm,I hereh.1,ccrtf(v Mar the ii vWq ioas 1%verv)c(insinteled in accordance
7.Is this a repo'-try an existing well: [3yes or Nn wnh iA,\CAt
11*1111"1."J.epair.cups ih,rea,rd ha,been prmvded to the evil wviter-
repair muter 2/ rvnwiarw)Me ha,-k e?/thisfi)rm. 23.Site diagram or additional well details:
8,For GeoprobeDI'Tor Closed-Loop Geothermal Wells having the same You mad use the back ofthv,papc�io provide additional well site details or well
construction.oil;, I is needed, Indicate TOTAL.NUMBER of wells collstruciiundetails. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth helow land surface: L7tJ (ft.)
4a. For All Wells: Submit this form within 30 days of completion of well
Formiduple well,1."w.'J"pili.,ildt(ler,m iLT11M/1/V-3!i_'(•200'and 2lieletif') constrLIC11011 to the Jbllo"-in&:
10.Static water'o,c!below top of casing: 8,75 (ft.) Division of Water Resoull-cies,Information Processing Unit,
fftvar.,r level is 411', 14w 1617 Mail Service Center.Raleigh,NC 27699-1617
11.Borehole diameter: P• (in.) 24h. For iniection Wells: In addition to sending the form to the address in 24a
J<A4-a r above.also submit one copy of this lon-n Nxithin 30 days of completion of well
:onstruction it)the following:
(i.e.auger.rotary.cage. 11[eCt push.vt,; IF
Division of Water Resources,Underground Injection Control Program,
FOR WATER S,PH.', WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: dbifo V 24c. For Water Supply& Injection Wells: In addition to sending the form to
to,(;/\Q Amount: J 4nk, the addr(:!�sws) above. also subiri it one cony of this form x0thin 30 days of
13b.Disinfectiofa-v­: completion of well construction to the coun't'y health department of the county
where constructed.
Foriii G,V-I North Carolina Department of Environmental Quah:%-01%iston of Water Re rarcrs Revised 2-22-2016