GW1--07181_Well Construction - GW1_20231101

GW-1 For Internal Use Only:
WELL CONSTRUCTION gECORD�1.We Contractor Information: '
z1 4PSVrTRZONE ` ;.
DESCRIPTION
mil-ROMTO
Well C tra for Name ,;
QItL11�TER ifa';licallle' ;s .: ::+ hi.
OIITER`GTG fosinulticasedwells s asi
'fel:5's:, TO D -
NCWell Contractor CertificationNumber FROM ,
Company
Well&Pump, INC �G1�CUB31ICr .eothermal 'Wag c°S :,:*-�;-3;^ ` ::`S•'
San t6;:R�lUgT0
®�-
W Cotiot ®®-�:•
2 plie(c well construction permits( M ,• >..,.? ,;•a:_;^, 1111 r "
111
List all applicable - _,:••� ='THICKNESS 17e:SCREEDC� D®
3.Well Use(check well�e)� ®
Water Supply Well: DMunicipaUPublic
Agricultural til/Water Supply(single) -- : .: ,._a;?
Supply) *R a ',.r,_
I cum *Residential u ©. ,�_ .F�-.,, :. ;..:t�::=•-• �z: -�,�.,.;.: „-,.,rHOD&attoDNx
Geothermal(miner g/Cocling PP l (shared) GROUT.':-?:: '''' EMPLACEMENTME
011111111
�j Residential Water Supply( FFROM TO
*1Indust1ia11Commercial it 20 ft anlill
o
XiMon
�ih=i:ation ®®
Non-Water Supply Well:
Recovery
Injection
..:f.r,i• ``"i'_s. r4
•
Injection Well: D•
GroundwaterRemediation �45 /GgaA I P.At mf ''i' �'le'€=�::......•....- oD
*Aquifer Recharge FRoat T�
®Ij Salinity Barer
*Aquifer Storage and Recovery ®IStormwaterDrainage � ...
Aquifer Test tz_ .:r s,_ • ',size,etc.
®ITracerence Control �,-_- GIAG-attacEarldi gpaTsl eets"fne ii etc
Experimental Technology ''>ZRDMIN DESCRIPTION color hardness,soillrack I. I.[�ExP �i Tracer FROM To
•Geothermal(Closed Loop) ft. �i 0 I..
®Geothermal(Heatmg/Cooling Return) it'Other(explain under#21 Remarks) d ft.
4.pate Well(s)Completed:
5a.Well Location: 1122113 .C. ft. 4aiiittorrigimmillil
1'OW1��+S WV Facility ID#(if applicable) lIllallillaIIINSIIIIIIIIIIIIIIIIIIIIII
Facil�ity//,�Oy+wnerNma G /,.
and Zip h
Physical Address,City, P � ��a� N
I'arcelIdentificationNo.(PIN) ill 5111/ 1141111111111111111
„ .t
County �t�E.•-'�La
longitude in de ees/minutes/seconds or decimal degrees:
gr 22.C • cation: II ��
5b.Latitude and longi sufficient) 1 ��
(if well field,one latllong is suffi )N ��. �
35 • �O Date
I Signs f • ed.Well Contractor
permanent or �TemPorary
By s mgarrn,I hereby certtfy that the well(s)was(were)constructed in accordance
6.Is(are)the well(s)t� with 15A 1JCAC 02C.0100 or�d�to the well owner.
Construction Standards'and that a
7.
If Is this a repair to an existing well:
•
yes or �o copy of this record has been p
the nature of the
23.Site diagram or additional well details:
If this is a repair,Trim out known well construction information and explainuse the back of this page to provide additional well site details or well
repair under#21 remarks section or on the back of this form• You may also attach additional pages if necessary.
•I Geothermal WellsUBER same construction details. You may
t g•For GeoprobeMPT or Closed-Loop ER the wells
construction,only 1 GW 1 is needed Indicate TOTALINMB SUBMITTAL INSTRUCTIONS
drilled:' Q _ft. 24a.For AIl Wells: Submit this form within 30 days of completion of well
For9.
multiple
well depth belowd land surface: 1 v� 00'and 2(a31000 ( ) constructionfollowing: Processing Unit,
multiple wells list all depths if top (example- (ft.) Division of Water Resources,InformationNC 27699-1617ssing(
10
fof casing: .�1 1617 Mail Service Center,Raleigh,
If Static water level casing,
use
the form to the address in 24a
I If water level is above diameter: 24b.For In ection Wells: In addition to sending
•
11.Borehole 6
(m) above,also submit one copy of this form within 30 days of completion of well
• rotary construction to the following: Injection Control Program,
•
12.Well construction ti dime t od etc.) Division of Water Resources,'Underground h,NC 276991636
(i.e.auger,rotary, 1636 Mail Service Center, the form to
FOR WATER SUPPLY WELL5 ONLY: &In"ection Wells: In addition to sending 30 days of
air pressure the For Waters above, also+submit one copy of this form within
Method of test: the addresses) health department of the county
13a.Yield Disinfection completion of well construction to the county
granulated chlorine Amount: where constructed
13b. type: Revised 2-22-2016
North Carolina Department of Environmental Quality-Division of Water Resources
•offi GW-1