GW1-2021-00838_Well Construction - GW1_20210322

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
J1hMES � 41ViEI l�►�50(1 14.WATR ONES
FROM 70 DESCRIPTION
Well Convector Name
n. n.
RC-WC- 4ao� R. R.
VC{`Well C<onuarct�orCm/ifrc`atinon tNumr-b.1elrr� t �• 15.OUTER CASING(FQ mdti�ed wells)OR LINER fit e)
(')P— 1 A R; 1I1 RQ :Inc— FROM R. TO t R. D1AMErER r. TDICRtE55 \L\'IFRLIL
Company Nam 161NNER CASING OR o0.J dosed-1 )
2.Well Construction Per'®t#: FROM To mea>ETER IIRQrT26 mAT'FnL+L
Lio all applicable well conome w,Pennin lie UfC.Comm St.,,.Yanance.ear.) R. R. m
3.Well Use(check well use): It. R. in. '
Water Supply Well: 17.SCREEN
FROM TO DUaa7ER SIMS= THICh�.IESS hL\7'ERIAL
Agricultural QMunicipal/Public It. fL tn.
Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) III. It. is
IndustriaUCommercial QResidenlial Water Supply(shared) 1&GROUT
Irrigation FROM TO hIATFRLAL EMPLACE 71i,1EfRODS AhIOLR,-r
Non-Water Supply Web: bit R. f R. _ _
Monitoring ORecovery ft. n.
Injection Wen:
R. R.
Aquifer Recharge QGroundwater Remediation
19.SANDlGRAVEI.PACK(if b4)
Aquifer Storage and Recovery DSalinity Barrier FROM To huTEauL 0IPLAMIENr NIET110D
Aquifer Test QStolmwatef Drainage
Experimental Technology Subsidence Control n. R.
Geothermal(Closed loop) QTmcef 20-DRD.I.ING LOG latrach addidoml sheets if necessary)
Geothermal(Hemin 'Cooling Return) ElOther(explain under#21 Remarks) FROM To a DESCBIPrgNta�ler.hrd•ea.m,Vrai >a.Nc)
It. fL
4.Date Well(s)Completed:01— — Well III# n. 33 t R. An
Sa Well Location: I. &ran 1
=rzaN lc Lv�n oc�n n. It.
Facility/Ownrr Name Facility lD#tifapplicable) It.
a n.
I'I•d1Ue�Ahi PLC, �L'940
Phvsical kdAm Cite and Zip R. R.
21.REAJARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/smonds or decimal degrees:
(if well field.one ludlong is sulTie ern) 22.Certification: \
N 11i
6.Ware)the we6(s) Permaoent or QTemporary !','M1XCACC
one ofenified well Contractor Dare
ng this form.1 herebp venifr that the .Wltr)uns Irrrre)ca.rruerrd in accordance
7.Is this a repair to an existing wen: QYes or No 12C.0100 or 15A NCAC 0>C.0200 Well Cmmrnatian 9andnrds ravel rho n
!f this u a repair Ill our brnun nr/l nnntr nrinn infomivown�ecplam der nmore nfdo, copy of this reeurd hat her.wo,idrd In rhr yell onrmr.
repair under#21 remarts section or on lire back of rhisfmn.
23.Site diagram or additional well details:
8.For Geopr ibe/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
convection-only I GW-1 is needed- indicate TOTAL NUMBF1t of wens construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
Fnrm.bip/euells lhiril/dlod.rifdifferrnilewrtple-3@700'and2l....100') construction to the following:
10.Static water level below lop of casing: 36 (ft) Division of Water Resources,Information Processing Unit,
!f umrr/e,e1 is.bore aurring.use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: W 011.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 1)Z I 1\I IMJ(i.e.auger,rotary.cabb h,direct perc etc) construction to the following:
IEvision of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: A�1 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) � f�J Method of test: R 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:hAkM�s Amount: c30 completion of Well construction to the county health department of the county
whore coaswc ied.
Farm GW-I North Caroh.Department of Ensimnmental Quality-Division of Water Resources Revised 2-2_1--2016