GW1-2021-00282_Well Construction - GW1_20210125

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WELL CONSTRUCTION RE( `D(GW-1) For Internal Use On'
Well Contractor Information: {
MWATEIR ZONES TO DESCRIPTIONWei ntmetorNameoC ��� t R.
aNC ZtICo Certification Number 15.OUTER CASING(for muI cased R LINER if a iicable
r FROM TO DU?IETER TH Ch,•�ESS _ ai ERIAL -
R in. 14710
UC_
Company Name
^� nx 16.tN\ER CASING ORTUBING thermaletosed-tan
2.Well Construction Permit!#: � D(/ FROM I TO I DIA.NIETER I THICKNESS I MATERIAL
List all applicable+cell constnecdon permits fix.UIC.Courn'.Srate.Variance•etc.) tt. R. in-
3.Well Use(check well use): R. IL nnu
17.SCREEN'
Water Supply Well: ,: '......
FROM - TO DIAMETER SLOT SIZE TH[Cl+•NESS 1 ERtAL
Agricultural �MunicipaUPublic t. io, Q
Geothermal(Heating/Cooling Supply)Mesidential Water Supply(single) ftR, in.
Industrial/Commercial ©Residential Water Supply(shared) 18:GROUT
IrriRation - FROM TO MATERIAL 11 _ - IPLACEMENTMETIIOD&A,IIOUNT
Non-Water Supply Well: R' R' - r
Monitoring ORecovery
Injection Well: ft. R.
Aquifer Recharge 0 Groundwater Remediation
19.SAND/GRAVEL PACK f applicable)
r:
Aquifer Storage and Recovery O Salinity Barrier FROM I To MATERIAL EMPLAC614t HOD
Aquifer Test OStonmvater Drainage ft. �R. r
Experimental Technology Subsidence Control
Geothermal(Closed Loop) ❑T,cer 20.DRILLING LOG(attacb additional sheets if necessary
F-RON I TO D&�CRIPTION fa,lor.Hardness.soiVroekly e. non sore.ere.)
Geothermal(Heating/Cooling Return) Other(explain tstder#21 Renarls) ft. R.
_ t
4.Date Well(s)Completed:1L Well IDt#
ft. R.
Sa.Well Locatio
�j� ft. t.
Facility/Owner Name FacilitylDO(ifapplieable) tt• ft.
fL
0 old' 9-P5
Physical Address,City,and Zip R. R•
,,�]J�• L, ` / e !J/1 t MARKS-'
County I. :\ I A�d Parcel[dentific No.(PIN)
5b.Latitude a d longitude In degreerdminutes/seconds or decimal degrees:
(if well field,one lalliongissuffcciem) _// 22.0 tifrcation: '
v l 'N 22 c2 ` 15 W. � �-nmr1&yC1-13-m?6a1
6.Is(are)the wells) Permanent or Temporary Signature of C ified Well Contractor Date
' By signing!his fame,1 hereby eertff)r that the mell(s)it-as(were)constructed in accordance
7.Is this a repair to an existing NveiL Yes orPnd,
No with 1 SA AVAC 02C..0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
ljthfs is a repair,fill ohrt kihonn n'ell coast uc:fon injornrarionxplain the nature the
cop)'of(his record has been provided to the urll`ouner.
repalrtmder N21 renhar ks section or on the back of t is form. 23.Site diagram or additional well detals:
. You may,use the back of this page to provide additional well site details or well
S.-For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-t is needed. Indicate TOTAL NUMBER o �off we 3� � construction details. You may also attach additional pages if necessary.
drilled f° rb,� " SUBMiTTA1:INSTRUCTIONS
9.Total well depth below land surface: n s ur—Lv s ')A- or 1 Ils: Submit',this form within 30 days of completion of well
For multiple utads list all depths fl'd joirent(example-3[Q200'aed 1 tny100') c` ion to the following:
10.Static water level below top of casing: : c� Division of Water Resources,Information Processing Unit,
lfnater level/s abow coing,use" f/ >;v{�� r�t'v 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter. (in.) �>> ' 24b.For Infection Wells: o!addition to sending the form to the address in 24,
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: ou-A construction to the following:
(i.r-auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground injeetion Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 5 Method of test:.idA4, 24c.For Water Supply&[niection Wcils: 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: T Amount: completion of well construct on to the county health department of the county
where constructed. r
Form G W-I North.Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016