GW1-2021-02534_Well Construction - GW1_20211015

WELL CONSTRUCTION RECORD(GW-1) For Intem l Use Onhy:
Ill Contractor Inf rotation:
?Lary ICAVATER?ONES
FROM -To DESCJ�UMOK
WeliConttmtorName ft. fl,
2 3a°► ''
NC Well Contractor Certi firntion Number
_ t 15.OiPI'ER CASING for mull-cowd velfs OR LINER rf e ' Me
FROM TO DIAMETER. Rf 7t7CAESS MATERIAL
R. R. fa.
Compam'Name Ili.RMVIN t CASING OR TUBINGIgeotharmal dowd400nl
2 FWM TODrAntETEtt Ttuaats staTestat.
List all tgi#kahle uv11 cvtmsntahm permits(i.e.VIC.County.STme.Ilvionty.erc.l C.
3.Well Ilse(cheek well use): It. 8 in.
i _
tYaterSupplyWell: FxaAi To auAa:rER Mar SIZE ralcharEss I MATERIAL ..
Agricultural [3Municipai/Public 0 ft. ti. is
,..Geothermal(Heating/Cooling Suppiy) DResidential Water Supply(single) `ft. dl D V
-Industrim!Commercial Weesidential'Water,Supply(shared) It GROUT .
Iltrigation FROM TO AtATEMAL ', E4/1%AGE1iERTAwntOD&AAtOU\T
Non Water Supply Well:
— _ .0 ,ft.. -
Monitoring Recovery ft. a1.
Injection Well:
Aquifer Recharge oGroundwater Remediation
19.SANDIGMYEL PACK. a ble'
Aquifer Storage mid.Recoven• 0saliaity'Barrier ;FROA1; To 1 1tATERiAL : . E1►►D'IACE IFMAtt'1Non
-,Aquifer Test 0stomnvater Drainage 7to & 5t
Experimental Technology [)Subsidence Control ft. fG
Geothermal(Closed Loop) 12Tracry as nR1LL c LOG=acmes aarlhiemal sleets 1f
FWD" TO DESCRUIMIN eder.hw&as.aeniexk _ to sim etc
EGeolbermal(Heatin Conlin Return) ;Other{ea; lainunder#21.Retnurks)
4.Date Well(s)-Completcd: /0 0
WeliIU# R.
Sa.Wen Locations
Fac7(ty/Qwnv tJatne Facility tDt(if ePpiicabie) R' IV D
tf. ft. ..,
Akavol
C_
Physical A and �: ft. OCT 1.5 2021
aL RE1HARtis
County oweell&wifrcation No.(PiN) ittlOtTilc'1tlQtl fQC2S81Fi9Unit
..R..
Sb.Latitude and.longitude in degreeshniouteshxcands or decimal degrees:
(if%yell field.on i Oong is sufficient) 22. ertill tuna:
3�,31t SUe► N 7(0 (a (0? 25'
6.Is(are)tht well(s)�ermanent or 1Temporarr Signature ofCertified 1Veii Conttactoi Date
$t «fining iMe Junn,i Irerehr ceitrf�thm rite nr!(fcJ a ac tirer>)'runstnnrgci in ac cr+rr/nuir
7.IS thug:a repatc tq all catiatiag veil; QYes er Id tr)/h ISM!11°°C�tt'n?tr.IIIOI!ar!SA Ar(AC It1t'.02ft0 tl i!!f'onrrreinirnr S?mtriarils mtr;ihm a
ydtis is a repair Jilt otu kt w aml i9 tuft ftltis t>'curd lrar heCnt prmided m r ell aaer.
repair wider=2J nemmi~r xeolon er an lute Iw&,?f4hrsfortu. a
33.Site diagramor;additianaF�elt_details+
8.Tor Geoprobe/DPT or Close&Loop Geothermal Wells baving the satire. �`��3'����of this page to p>ovide additional t��ell.site:details or tiyetl
construction,only l OW-1;is needed. Indite-TOTAL TOTAL NUMBER of>weils �nstrubtion details 'You final also attach additional pages;if necessary.
awned: stiprOn TAL lNs•FRt1cr-lo'S
9.Total well depth balmy land surface:,_„- ._ 00 248, For At1 WId' .Submit-Ibis form within 30 days of completion of'svell
For muhiple tretls ltn all depths TrllJTerew(ezmuple-3 rni 200?wd 2t?1M conyyruction,to:the folloN%ing:
10.Static water level ttd( top of casing: V (ft) Division gf Water t2esonre hiformetton Processing tluiL
If uvrcr•level is ahem coshtg,my " � 1617 XIaH SeInice Center,Raleigh,NC 27699-161
11.Borehole diameter._ r 5 (in.) 24b.For lnieetian`1i'et1s: .t t additlon 1d sendingdte form-to the address in 24a
above.also submit cme copy of this form mriihin 30 days of completion of weil
12.R'eli cottstraction metbad: e� construction to the folkm ing:
(i.e.anger,rows.cable.direct push.etc.)
Division of Water Resources,Underground lejection Coatrol Program,
FOR WATER SUPPLY WELLS ONLY:' 1636'Mail Service Center,Raleigh.NC 27699-1636
13s.Yield(gent) Method of test: 1 fl\t� 24c.For Ni'atrs.Suon(v&iniecuon Yeur. in addition w sendIng the form to
the address(es) above, also submit one Copy of this,form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county bealth department of the county
%vhere constructed
Cc S-e►\+ _AX-
Form GW-1 North Carolina Department of Emironmemal Qualiis•-Division of%Vater Rwo u= Re%ised 2 222016