GW1-2021-02802_Well Construction - GW1_20211118

WL+LL UVINSTRUCTION RECORD (GW 11 For Internal Use Onlq: Y-`-
1.Well Contractor Information:
14yL `D©GI n e p 14.-vpAT�R zoN>s .' •
Well Contractor Name V FROM TO DESCRIPrIppt '
'7 0 ;3 ''�' ( j ft. 02 ft,
A
NC Well Contractor Certification Number �'11 fL IZ ft. q(' C4
G[ 1_,e As.OIITER CASING fotinintti cased we is,OR LINER s' Ucable
11�/ II Dry mini FROM TO DIAMETER T$ICIQVESS MATERIAL
Company Name P/C
=16:IIVIVER CASING QR"TM11Y(--{eothermal closed-moo Yl
2.Well Construction Permit#: FAOM TO_ DIAMETER THIC[WESS MATERIAL
List all applicable well construction permW(Le-UIC Couat);Stag Variairm etc.) p• R, in.
3.Weil Use(checirwell use): tt. ft. in
W r Supply Well; T SCREEN' ;'; .-
FROM TO DIAMETER SLOT SIZE TMCX NESS MATERIAL
Agricultural E)Mnnicipal/Public & fL in.
Geothermal(Heating/Cooling Supply) oRmidentiai Vater Supply(single) ft ft. 1n.
Industrial/Commercial +©IResidential Water Supply(shared)
19 GROUPIrrigation T . . _ ••" = i ,
FROM TO t��J�
7� M
14G` eothennal
on-Water Supply Well: 0 ft. 20 ft. It
Monitoring Recovery tL fL
jection Well:
Aquifer Recharge f ft.
9u13Groundwater Remediation
Aquifer Storage and Recovery 19.;SAND/G_RAVEL'PACg cry �SallIIlty Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test �IStormwater Drainage ft ft
Experimental Technology [3Subsidence Control ft. ft
Geothermal(ClosedLoop) Tracer 20.DRILL•INGLOG,(attachaiiliNaualsheetsifnecess(Heating/C ooling Return) MOther(explain under#21 Remarks) I
FROM TO DESCRIPTION color,hardn oitfrock rain sim etc.)
4.Date Well(s)Completed: �-1'1. �i WellID# ft' -75 „S�t f ni
5a.Well Location: ft. �V 'U R.
Luke 561 ey ft. ft
Facility/OwnerNamc Facility 1D#(if applicable) R• ft. .
R e U arras From 392 kcau6a adesvIL ,�7 ft.
i21
AmAddress,City,and tip ft. ft.e -21.REMARKS
DWR SEC
County Parcel Identification No.(P1N) INTORMATION PROCESSING UNI1
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long is sufficient) / 22.Certification:
36-Lt LOT N f(I-`fay y
'12-Z021
6.ls(are)the wellwepermanent or OTemporary Signature of Certified well CjgWftr Date
By signing this form,I hereby cer0 that the 1-JI s)was 6wrel constructed in accordance
7.Is this a-repair to an existing well: 13Yes or exo widz 15A NCAC 02C.0100 or 15d NC✓fC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out latom well construction h formation and explain the nature of the copy of this record has been provided to the weltowner.
repair under#21 remarks section or on the back of this form
23.Site diagram or additional well detans:
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-i is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1�O. (ft) 243.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3©200'and 2©1001 construction to the following.
10.Static water level below top of casing: (fk) Division of Water Resources,Information Process'
Ijwvter level is above casing,/use••+" 1617 Ma31 Service Center,'Raleigh,NC 27699-167 rut;
11.Borehole diameter:C7 ��� (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
.12.'Well construction method:Al r Marg above,also submit one copy of this form within 30 days of completion of well
CLe.auger,rotary,cable,direct push,eta) construction to the following.
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)Z( Method of test: 1'r 1-1 f� 24c.For Water Supply&Injection Wells: In addition to sending the form to
(� the address(es) above, also submit'one copy of this form within 30 days of
13b.Disinfection type: 1 rfff Amount: OZ completion of well construction to;the county health department of the county
where constructed.
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016