GW1-2021-01718_Well Construction - GW1_20210215

WELL CONSTRUCTION RE( `D (GW-1) For tntemal Use On'
1.Well ontrac Information:
4714,WATER ZONES
FROM TO DESCRIPTION
c Contt ajctorrName
� / ft
.
NC Well tractor . iri�catip)p!Number 15.OUTER CASING for muld•cased wells OR LINER if a likable
FROM TO DL4.\I ETER THIClUiESS I AI ERIAL
© R, fL in. �r
Company Name / /, f6.INNER CASING ORT[JBING eothermalclosed-loo
2.WellConstructionPermit#: /V /V O E�oat To D.AaterER rxtcic�Ess MATER11
List all applicable hell construction permits f.e.L11C.Coimn State,Variance,etc) R• R. is
In.
3.Well Use(check well use):
I7.SCREEN:
Water Supply Well: FROM I TO' DIAMETER I SLOT SIZE ICKNESS tATERIAL
Agricultural 0Municipal/Public tt. R. In. C U�
Geothermal(Heating/Cooling Supply) residential Water Supply(single) R• R, in.
Industrial/Commercial QResidential Water Supply(shared)P Y ) 18:GROUT
FROM I TO ERIAL '0 I-ACEMENrMETHOD&AM LINT
Non-Water Supply Well: R' 0 R--
Monitoring Recovet R. R,
Injection Well: ft. it.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK f sop Ileable
Aquifer Storage and Recovery Salinity Barrier ERMM. AIKfERIAL EMPLA EfHOD
Aquifer Test [3Stonnvti-aterDraina2e
Experimental Technology DSubsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attacb additional sheets if necessary
rm
i E140M TO DESCRIPTION(color.hardness.soiVrocktc e.grain sire.etc.
Geothermal(Heating/Cooling Return) rl Other(explain under#21 Rends)TI
O t. ft-
4.Date Well(s)Completed: of Well ID#
XMARKS
5a.Well Location:
cili 1D0 tfapplicable)
Facility/Owner Name tY (•
Physicat Ad Ciry/,alld ZiP /J A +
County Parcel Identification No..(PIN)
5b.Latitude and longitude in degreeslnitnuteslseconds or decimal degrees: R
(if well field,one latflong is sufficient) r1 Certification:
v � 8-1p,A
Q
t�
1'a � rtifi el►Contractor Date
OPernent or Ignatmd,
6.Is(AM)thewe6(s) o
�3igt)t is form,1 hereby cer(yy that the uell(s)trac(were)consmtaed.ht accordance
7.Is this a repair to an existing welt: s or No Fria �y iiiihUl�4 NCA.C.02C.nlOU orISA NCAC 02C.0200 Well Construction Standards and that n
!!this is a repair,fill out Anonn well construe on injornmtion and explain Ire nanrre oJtka
of this record has been provided to the uelPonner.
repair tinder 021 remarks section a)•on the back of this fort. ram''' v 23.Site diagram or additional well details:
J`V+ You may use the back of this page to provide additional well site details or well
B..For CeoprobP/DPT or Closed-Loop Geothermal Wells having'Lire same construction details. You may also attach additional pages if necessary.
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: tipSUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / 0- Aft-) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dii&rent(eraalple-3Q 200'and 2r1g 1W) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifumter level Is above casing.use"/ 1617 Mail Service Center,Raleigh,NC 276994617
I1.Borehole diameter: L n.) 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: construction to the following:
(i.e auger,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) V Method of test: lw 24c. For Water Supply&Iniection 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:-�1-T 4— Amount: completion of well construction to the county health department of the county
where constructed.
Fonn G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016