GW1-2021-02528_Well Construction - GW1_20210805

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: i
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1.Well Contractor Information:
dnlll�j(a(1 V f l Zt t�� la.WATER ZONES
Well Contractor\antr FROM TO p DESCRIPTIOX
q0.� Q ft. 1 l ft. '
I q p rl. , 21qs- ft. 1 40116 tJ
NC well Connacto:C'enitication Nunibet 15.OUTER CASING for multi cased wells OR LINER of a licable
AW�-y a,,,- j FRONT TO Dt4METER T,.Z"ESS MATERIAL
L SCN✓�Q S! I n C ft. ft. in.
Company"Name
,
/J'�
� 16.INNER CASING OR Tt H1NG othermnl closed-too
2.Well Construction Permit#: `^ "' FROM TO I DIAMETER; THICKNESS MATERIAL
l iv all a p/lrahle c 4,-.,wrurirrut peraw,Ii.c.f 7t:t�rturt:�.tiratet !irrturtcz'.+•!ct t r►� ft• r ft. (, ry5 ;in, .�� V C,
3.Well Use(check well use):
V £t. ft. t G• in.
��
water Supply tN e11: 17.SCREEN
FROM TO I DIAMETER 1,SLOTSIZF. THIC'KSESS MATERIAL
Agricultural [D lcipal/Public ft. ft. in. ,
Geothermal OIL-nunalCooline Supply) Qkesidential Water Supply(single) A
X ft. I ft ;n.
Industrial/Cor.-. mind Residential Water Supply(shared)
18.GROUT
Irrigation FROM 1 TO 360"
TERIAL F.MPLACEMEST METHOD&AMOttNF
Non-Water Supply Well: O fr. �+ C) ft. 1 ! �
Monitoring Recovery ft. ft. '
Injection Well:
ft. I ft, t
Aquifer Rechu:_e nGraundwater Remediation
)9.SAINT RAt'F,L PACK([fa licable)
Aquifer [Oral.nn..f S�CCttV@(Y �Sa1i111[y Barrier FROM I TO MATERIAL EMPLACEMENT NIETHOD
Aquifer Test [3 Storm++ater Drainage
fr, ! €t
Experimental eenno!ogy 1OSubsidence Control ! l;. ft i
Geothermal iC:,sr Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessa )
FROM 'to DESCRIPTIO\(color,hardness,soil/rock t rain size,etc.
Geothermal(H__a.:a.Cooling Returns Other(explain under#21 Remarks) i o A, 'j tp C kc-6 10�A�V.VU__f%
4.Date Well(s)(ompleted:�"�J ( well Iwo Grab% Feon
NJ
ft.
5a.Well Locari:�.,:
Bes/crly IZNZrMarl j ft. ft. �
Facility Owne \a: _ Facili:y ID4 01'applicablr f:. ! ft.
o wad ._('xt �afd !, Cnal��c,NC. u1Is' r:. ft.
Ph(yssical Address.Cin.:md Zip �r /+ ( fr. ft.
U u.n '1 6n%IX ��-I---D--.����q'T'"7GQ�Q� 2i.RE�t.vRKS Cl
Lour m Parcel ldenli lication No.I PIN;
Latitude ane ion-litude in degrees/minutes/seconds or decimal degrees: l
(ifweil field,one i:r log_•is;ti ficient) 22.1`er ification:
'3�� t�. 5gys t2644' 3�. uc�lZto2 ti�
6.Ware)the++c l(s) PermanenI or [3Temporar} 8nature o3onifie N'cIl Contractor Date
Hv signing r'm+darn+,I"herebY cc,q6-Thar the xcll(sl wa.,hrerer-caarlrucled in accordance
7,Is this a repa i-to:!n existing wetl: E)I-es or tt wah 15A A AC IOC.0101,or l_`A NCAC 02C_02011 Wel(('uuatrrrcuull,Slandurllc and dial a
If/hie lea r pow.r"ov! annr tit l/crn,im ran information and asp/arn the mourn iffhe c apr of l/x,re,rrd Ituo hecn prowled to the a it moier.
repair mul-t- _'I rrr:::rc,,rcnaa ur nn ltr;•hack oj7hr.c li>rm.
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.on:- !('v,-I is needed. Indicate•T'OT.AI.NUMBER of wells construcittin details. You may also attach additional pages if necessary,
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drilled: SUBMITTAL INSTRUCTIONS
4.Total well depth hero+e land surface: � � 5 (ft-) 24a. For Ail !Fells: Submit this form within 30 days of completion of well
Por multiple well,t.,+urn dtysdts it,h(J:r;:n lceample-3.t 3O(1'and?(tP!!I(1'1 constructiontO the following:
10..Static water Ie'"C!below top of easing: (ft.) Division of Water Resources.Information Processing Unit,
If trafer lerel is al,„r..n:"',ime' 1617 Mail Service Center.RiIeigh,NC 27644-1617
11.Borehole diameter: l0 Se' (in.) 24b. For Injection Wells: in addition to sending the form to the address in 24a
XD � above. aisn submit one copy of this farm within 30 days of completion of well
12.Well constr::_ on m r'li ethod: construci:on to the following:
I i.e.auger.rotary. diittct push.etc.r
Division of Water Resources,Underground Injection Control Program,
FOR NVATER SE PHA WELLS ONLY: 1636 Mail Service Center.Raleigh,NC 27699-1636
13a.Yield{gpml�_ 1S Method of test:�A�. fl'I G 24c. For%%Cater Sunnly a;: Iniection Wells: In addition to sending the form to
the addre:.s(es) above. also submit lane copy" of this form within 30 days of
ty- I 13b.Disinfectiw!'v-:: (or Amount: z1b1 completion of well construction to the count health department of the county
++here constructed. t
Fong G'A%I Nonh Carolina Department of En%ironniental Ottah:x-Di+tston of Water Resolirccs Revised 2-22-20)6
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