GW1-2021-06941_Well Construction - GW1_20210505

P•i
WELL CONSTRUCTION RECORDIGW-1) For Internal U.e Only:
1.Well Contractor Information:
Jamtsc
14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor N.1 i:_ ri ft. ft. law
1 179" d)E>
Nr Well Contracit,, Nurtho;- 15,OUTLR CASE 6(for T!L1_ti,, sved wells)OR LINER(if it!lcablle)
C A Inc ft. I D, TER I THICKNESS MATERIAL
Cornpiny Nanic I6�1.;\N E R CASI NG OR T U!L],�, Gjgeothcrinal elosed-Intial
Ir'ER
2.Well Construction Permit 0 Irs 3 F To 'I THICKNESS MATERIAL
- I G ft. in. �DK
e V C.fill"
3.Well Ise(check:hell use):
Water Supply\\cil: 017.SC R E F,.N
FROM TO DIAMETER SLOT SIZE THICKNESS INIATERIA1.
c"Agriuiturai a)/Publicin.
G
� ILI I(I sident Water Suppl.v(Single) in.
eo ierma ling Supply) esti.lial
R�
11dastrial/Con idential Water Sul (shared)
1 18,GROI T
Irrication FRONI "I'D 11ATERIAt, EMPLACENI N'T METHOD&AMOUNT I
Non-Vii'ater 0 7 0
0
7)Monitorine E3 Recovery
Injection Well: ft.
Aq at ler Rech:.. [30-ouridvtatcr Rerriediation
.L PAC f 'icahe'
:JAquifer StOrilL. '1'e 11:0Ver\ [3Salinav Barrie, i FROM TO kj'i1T21M_._A1 I EMPLACEMENTmrTHOD
AquiterTest OStormwatcr Drainage ft.
Experimental c,,nnolo_a� nSubsidence Control
Geothermal Loop) [3Tracer 20.DRII.I.ING IA)G(attach additional;sheets ifnecessary)
FROM TO DES('RIPTION(colon hardness,soil/rock lype.grain size.etc.)
Geothermal 0 1 ,2 r ('ool inL,Rewril) MOther(explain Linder#21 Remarks I
wit. 2.(o f" UeAy /,OvtA, k>CA-k-OLL-pl
4.Date Well(s)(tliapleted:4 Well ID* 40 S—"' 6 14—
2A0
5a.Well Locati,
ft.
or r fc,
Ftkci!it\0%kncr\a Facility ID-(if3pplicablc) ft.
ft,
314 01cl Ed AkyanaUg,NC_ 287 01
Physical Address.(lt\ :ino/ip ft. ft. 5,
=WC II ED 410 21.REMARKS
-46L
Parcel Identification No (PIN) roceing units
DVVR SeCtOn
-/minutes/ -decimal degrees:5b.Latitude an.., !on,-4tude in degrees seconds of e
(if\\ell field.one k�:'ory�,"tifficielit
2Xtitian:
A5 a 14,t;�1.4;2 71-%Z--\ 3?Z6,3tp' a,J)qJ) 2 \N- Lq__6
gnatnrc,.:'(enified Well Coiitni.tor Dare
6.Is(arc)the%i r;;t,,)trVermflneid or OTempoary fit ijtpmt..:fm,ionn, I herehY ,ti4i that iliv wediv;irti�imvrel constructed fit accordance
7.Is thiti a repi" ��xisting A%,i : []I-es or ;;;�a ;,,'ft2(*.I;li);'j,,rli,-I.\*(*,4('tj2('-fi2t)flJiellioi7.,Irticli,)I?,I;iiii(lir.lvai?(Iihato
ffflo,t,"'vIvir," 11e;1 non ollonnotion on,/explaof Ifte owurvol the rank of av,.-ont has been providvd io the twiloirner.
repoil.imelor 7/r. lion orwi rilo blick of i/ov form. 23.Site diagram or additional well details-.
8.For Geop -rob bF for Clo--ed-Loop Geothermal Wells having the same YOU may .Ise the back of this page;to provide additional well site details or well
construction.o". is needed, Indicate TOTAL N(;MBLR of,.velis 1�011SVUCI:•+.-,details. You ma"alsoiiiach additional pages if necessary.
drilled:--.. - St BMI'I !*.\I,INSTRUCTIONS I
9.Total well dcl,th iiiejo%v land surface: - .2 ft-) 24a. For All Wells: Submit ih;s' form wiftin 30 days of completion of well
A construcuon to the following
^
10.Static water I.- below top of casing: rV Division of Water Resources,Information Processing Unit,
11 waler letvii i,........i1q, 1617 Mail Service(!enter.Raleigh,NC 27699-1617
i
11.Borehole d1.!:1!i?Te1': to (in.) 24h. For Injection Wells: In addition-,o sending the form to the address in 24a
above. ai�o submit one copy w'tHlis 11orn, within 30 days of completion of well
12.Well consir,—tol:method:...ithae,!I
:onstruc._:.to the following i
(i.c,attel:r, act push.etc
Divisiun of Water Resources,i nderground Injection Control Program,
FOR"ATERI. WELLS ONLY.- 1636 Mail Service Center.Raleigh,NC 27699-1636
13a,Yield(gpnii__ 3-D Method of test:06d, (15f)tC64e4l 24c. For Water Sullpl%-& Injection Wells: In addition to sending the form to
the above. also SLIbililt on: cope of this form within 30 days of
13h.Disinfectio, wpt.: Amount: :ompleticn of well construction to the county health department of the county
there cor-itructed
Finn G'-',-I North Carolina Department of mironirle;,,ii;Oualu.\ Revised 222-2016