GW1-2021-00441_Well Construction - GW1_20210201

WELL CONSTRUCTION REC `D(GW"1) For Internal Use On'
1.W Contractor Info r ation:
14.WATER ZONES
rFRO,-ITO DESCRIPTIONWeIlCont orN tnee ft.NC W tractor Ce r on umber CASING Cor multi casedwells OR LINER ifa IlcabteTO DL1\I Er ER Ta""t ESS _ MAT RIAL
Q R. "L in. v
Company Name t6.INNER CAS[NGORTUBING thermal closed-too
2.Well Construction Permit k: �,V�/ b�O../t a 5'9� F
ROM To DtXN1VTER THICKNESS MATERIAL
List all applicable ssrll construction permits fix.UiC.Courry.Stare.Variance.etc.) R• R' io
3.Well Use(check well use): ;a
Water Supply Well: I TO DIA519FER I SLOTSIZE I THICKNESS MATERIAL
Agricultural MunicipaVPublic t. �t: to. a v
Geothermal(Heating/Cooling Supply) esidential Water Supply(single)
Industrial/Commercial OResidential Water Supply(shared) .18.GROUT
irrinti0n - FROM TO MATERIAL -E\ CEME\TMETHOD&AMOUNT
Non-Water Supply Well: ft-
t 0 R'
Monitoring Recovery ft. tt. 47
Injection Well: ft. tt.
Aquifer Recharge 0 Groundwater Remediation
19.SAND/GRAVEL PACK f applicable) -:C
Aquifer Storage and Recovery O Salinity Barrier FROM TO I MATERIAL EMPLA04iNIENTMETHOD
Aquifer Test DStonmvater Drairaee D R. ft.
Experimental Technology [DSubsidenceControl
Geothermal(Closed Loop) Q Tracer 20.DRILLING LOG(attach additional sheets if necessary
FROM I TO DESCRIPTION(cotor.bardne s.soltfrocktype.grainsive.etc.
Geothermal(Heating/Cooling Return) Other(explain tmder=21 Rem!2 i ft. ft.
4.Date Well(s)Completed: t IDt€ f m
tt. N..J ft.
a.Weil Location:
S'. Ct.
Facility/Owner Name Facility) (ifopplicable) R' ft'
ft. ft.
Physical Ad City,and ip
wl 2L7tEMARK5
County Parcel identification No..(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(irwell field,one latflong is sufficient) 22.CqAification:
C
"VAL
6.Is(are)the wetl(s)v Permanent or Temporary Signature erti@ed well Contractor Date
kv signing this form,i hereby certh that the ssell(s)uars(were)constructed in accordance
7.Is this a repair to an existing well: QYes or" to %dih 15A NC.A.0 01C..0100 a)-15A NCAC 02C.0100 Well Construction Standards and(hata
Ijthis is a repair,fill our k'noon%veld construction information and explain the nature of the cop}o(dris record has been provided to the uefl'gnner.
repair under#21 remarks section or on due back of this form. 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
I
onstruction,only 1 GW-1 is needed. indicate TOTAL NUMBER ofwells 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
For mukiple mells list all depths if d(Qerenr(example-3 _00'writ @100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
!fitter letvl Is above casing,Erse '- 1617 Mail Service,Center,Raleigh,NC 27699-1617
Ll
It.Borehole diameter: (in.) 24b.For Iniection Wells: In4addition to sending the form to die address in 24a
above,also submit one copy of this font 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: r 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 11 Method of test: 124�? 24c.For Water SuPPIV&In'iection 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: CTTl7 Amount: completion of well construction to the county health department of the county
where constructed.
Font G W-i North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016