GW1-2021-01199_Well Construction - GW1_20210209

1.V WELL CONSTRUCnON RECORD(GW-1) For Intemal Use Only:
'ell Contractor In rmation:
d� 14.WATER ZONES
Well Contractor Name FROM TO I DESCRnrnON
.23GJq-N ft. R.
rt. R.
N Well Contractor Certification Number 15.OUTER CASING for multi-eased wellal OR LINKER fifanniiiniahipi
FROM TO DIXMETER THICKNESS alATERIAL
w Company Name in.
16.INNER CASING, TItBING.(geothermal dosed400nl
2.Well Construction Permit#: FROI To DIAMETER THICICKESS I MATERIAL
l.ish ulI applicable ueil a>rrVnrninn perniits/i.e.i?IC.Caunis;Stan.l'arimue.etc.) •k.l♦ R. Q�� R, in. /L!� u�
3.Well Use(check well use): ' R• ft. in. 7�
Water Supply\'1'Cll: 17.SFROMREE TO I DIAMETER I SLOTSi2E I THICKNESS I MATERiAL
Agricultural [3Municipal/Public 0 ll R. ,L in. 0� �It pifG
Geothermal(Heatinp/Cooling Supply) Residential Water Supply(single) R ft.
�f i� a IT V
Industrial/Commercial [3Residential Water Supply(shared) ts.GROUT c`
.r17 t1On FAOM TO MA RiAL E1V1PLAM%MENT METHOD S Aiilobyr
Non-Water Supply Well: 2L.0 ft. OLA&
Monitoring 0 Recovery ft. R. l
Injection Well: ft ft
Aquifer Recharge oGroundwater Remediation
19.SAND/GRAVEL PACK Ofavitlicablel
Aquifer Storage and Recover}• [Salinity Barrier FROM 70 11ATERiAL 11iPI ACEIIENT i1EI HOD
.<Aquifer Test DStomtvvater Drainage t�p R. `t, R. Sk
O
Experimental Technology DSubsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG fattach additional sheets ifnecessa •
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) I FROM R. To fr. DESCRIMON color,hardness.soiuroct in Size,etc.
4.Date\Yell(s)Completed:/2 �0 Well ID# ft. R.
Sa.Well Location• ft. ft.
it
IAS Facility/Owner Name Facility iD`(if applicable) R• R-
#\" s-C'RE C 0(.O W l, ft. fL e� awe 7 cP 1
Phi, -ZO Chi and Zip it. ft.
21.REhL4RKS 821
County Parcel identification No.(PIN) Irf r_,.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: D`�VR SQC('Oil
(if well field,one inviong is sufficient) 22. ertifieation•
1 .27 21
6.Ware)the well(s)oPennanent or Temporary Signature £Certified Well Contractor Date
Ay signing this form.I herr:hv cert!ft•thin ire avl/(s)was(it-ere)c(nsinicied in awordaiwe
7.Is this a repair to an existing well: [3Yes or Z`0 with ISA AICAC 02C.0100 ar 114 AICAC 02C.020011eil Cansinicsimi 9mhdaniv mid dial o
If this is a repair•fill ont kttmm Weil cal istrrellon informadan mid c rplain the irmure of the copy of tils record has been prowded wA
p will ouwer.
repair raider-21 mutarbasecumt or air►he hack of this form.
23.Site diagram or additionat 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.only i GW-i is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: `\ (n•) 24a. For All Wells: Submit this form within 30 days of completion of well
For mul iple irells list all depths if different(example-3 n 200'and 2n1001 construction to the following: a++
10.Static water level Wovv top of casing: )ICO A) Division of Water Resources,Information Processing Unit.
If starer iere/is ahore casing.use••-- � . 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 7. (in.) tab.For Injection Wells: In addition to sending the form to the address in 24a
12. ��\ above. also submit one copy of this form within 30 days of completion of well
(i.e.Well construction method:.auger,totan•,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh.NC 27699-1636
13a.Yield(gpm) 30 Method of test: Ril%ft,n_ 24c.For ater Sunniv&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: Amount: Vx C,tAQ completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Depanment of Environmental Qualify-Division of Water Resources Revised 2-22-2016