GW1-2021-06914_Well Construction - GW1_20210505

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: i
ZGS �
M I Sej 1 � 1, I� �� 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
/:O,ffyt- 100 ft. 1 I a,—,
NC Well Contractor Certification Number is.OFFER CASING(for multi-cased wells)OR LINER(if a Iicable
` FROM TO DIAMETER THICKNESS MATERIAL
�� �A-CZS �C in.
Company Name
16.INNER CASING OR Tl1BING(geothermal closed-loop)
2.Well Construction Permit#:ii20 j OD I�� V V t� FROM TO DIAMETER THICKNESS MATERIAL
l ivi all applicable rnell convn•nciinn pernviis(i.e.1//C'.Conng•,Sate, Variance,ele) 0 ft. �Q' 1t- �,?5 in. c 21 1 V C-
3.Well Use(check well use): ft. (! ft. v in. J
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL,
Agricultural IVIside'ntial
al/Public ft. f. in.
Geothermal(Heating/Cooling Supply) Water SuPPIY(single)
it. ft. in.
71 Industrial/Commercial ®Residential Water Supply(shared) 18.GROUT
Irri atlon FROM TO MATERIAL EMPLACEMENT METHOD AMOUNT
Non-Water Supply Well: ft. .7C) ft I' BIZ
Monitoring ®Recovery ft. ft.
Injection Well: t
ft. ft.
f Aquifer Recharge ®)Groundwater Remediation
19.SAND/G RAVEL PACK(if a Iicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology nSubsidence Control
Geothermal(Closed Loop) nTracer 20.DRILLING LOG(attach additional sheets if necessary
Geothermal(Heating/Cooling Return) !Other(explain under 421 Remarks) FROMTo DESCRIPTION(color,hardness,soilhrock e,grain size,etc.
ft. ft. CIS Ov r
4.Date,Well(s)Completed:3�IS=0�1 Well ID# S ft. es- ft. ! n r�e
5a.Well Location:
ft. I ft.
0 alas � rs�
Facility/O ner Name Facility ID#(ifapplicable) ft. ft.
6 0, 2 (Zd 14eno(t2.ysanJ�1\e NG �8TQz it. ft. F.-
Physical Address.City.and Zip
21.REA q '` ft. ft. j ti ..ro
7ARKS X
2021
County Parcel Identification No.(PIN) m.4
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: x• _�. .pf:47- i
(ifwell field,one lavlong is sufficient) 22.Certification: 13d nt"a `o�j'pi1
v
°a ' N 1z0 .73 I SS. ToL4 w i 3'IS-c'�
...-r-
6.Is(are)the well(s) i' ermanent or OTempo;�o
granite of Certified Well Contractor 1 Date
13e signing this form,I herehy verb/:,thai the uell(vi ryas(were)constructed in accordance
7.Is this a repair to ar,existing well: nYes or vith 15A NUAC 02('.0100 or 15A NCAC 02C.0200 lfc//Consirucoon Standardv and that a
/f this is a repair.fill out knmrn u e//cnnsu•uctio»io/brwation and explain the nature gfihe copy ofthn record has peen provider/ra the rreh miner.
repair under a 21 remarks section or on the hack of ihis faun.
23.Site diagram or additional 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 if necessary.
drilled: d SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ( O 5 A) 24a- For All Wells: Submit this form within 30 days of completion of well
For nndtiple rrelly hvi all depths ifdifferent(example-3@200'and 2@100') constnlMion to the following:
10.Static water level below top of casing: n:gf10V' Y'q (ft.) Division of Water Resources,Information Processing Unit,
Ifu•ater/eve/is above cosh g,use" �•4•e,$1 C.LYY 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: lD• 2 (in.) 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: constructon to the following:
(i.e.augerr..rotary,cable..direct push.etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c. For Water Supply& Iniection Wells: In addition to sending the form to
v the address(es) above, also submit,one copy of this form within 30 days of
13b.Disinfection type: W0(e 1,SL Amount: completion of well construction to the county health department of the county
where constructed. f
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016