GW1-2021-03534_Well Construction - GW1_20210607

WELL CONSTRUCTION RECORD(Gw-n For Internal Use Only:
I
1.Well Contractor Information: '
14.WATER ZONES
wen ConnactorName FROM TO I DESCRIMON
355 n 360 ft- "I a! �P"^
s 90 `Ir
NC Well Contractor Certification Number 15.OUTER CASING for moltiiased wells OR LIl�IER da ble
t ` ( FROM TO DIAMETER; TBICt;Ng49 MATERIAL
�h s)eu c weft Jeri �1 � 111 L, �� Ic I 'A9 n A in. 0,;z10C-Wan C�
r Nye t I&WNER CASING OR TUBING tbermal aosed-too
2.Well Construction Permit#: 3 3 S s0 i FROM To DIAalEIER I Ti11CBNM MATERIAL
List all applicable well construction permits(I e.VIC,County.State,Variance,etc.) IL R. im
3.Well Use(cheek well use): ft, ft' in.
IV
Water Su Well: 17.SCREEN
Pply FROM TO DIAMETER SLOT SIZE MUCEMM MATERIAL
3AVicultural [3Municip&Public 0 IL It. in
Geothermal(F-Ieating/Cooling Supply) Residential water Supply(single) tt ft. is
IndustriaVCommercial Residential Water Supply(shared) IL GROUT
FROM TO MATERIAL METHOD&AMOUNT
Non-Water Supply Well: Q ft' 3 ft Celret u-" .k
Monitoring OR—cry 3 ft- Z O ft 0 i�l�
Injection Well:
ft. iG
Recharge OGroundwater Remedistion
f Storage Recovery OSalinity M SAND/ I -fo PACti hf a ble
er and Barrier FROM 1+0 MATERIAL EMPLACEM@iTMETHOD
Aquifer Test OStormwater Drainage &
Faperimental Technology OSubsidence Control
;
Geothermal(Closed Loop) OTracer 2&DRMLING TAG attach additional abeets Rnecessa
Geothermal(Heating/Cooiing Return) 00ther(explain under#21 Remarks) I FROM TO DESCRIPTION mbr,mrdsess,soW,.k —4 et-
2z p fL ft 0i5 Sou
4.Date Well(s)Completed: oZ� Wcu ID# J J��O 1 p ft- a(o ft-
Ss.wen Location:
ll a �0
R
ML Facility/Owner Name Facility M#(if applicable)
39'35 00 (J Aa tosTS �-eh '0r-To -
Physiyll Address,City,and Zip tt. tt
,Vf�f 'CeJ Ut33 'OA0O 5-4 21.REMARKS
County Parcel Identification No.(PIIo t Y+. Cless1i1, Hit
)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
:3(,,,o IS N r1�sa 30
Db oa- boa
6.Is(are)the well(s)IRPermanent or OTemporary Sigaatme ofeertifiedWell Contractor . Dat
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or JqNo with ISA NCAC 02C.0I00 or 15ANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,full out brown well construction information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair router 921 remarks section or on the buck ofihis form.
23.Site diagram or additional well details:
S.For GeoprobeoPl'or Closed-Loop Geothermal Wells having the same You may use the back of this page Ito provide additional well site details or well
construction,only 1 GW-1 is needed Indicate TOTAL NUMBER of wells constructionYou may also attach additional pages if necessary.
I ff SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: W 0 YL) 24a. For All Wells: Submit this!form within 30 days of completion of well
For multiple wells list all depda tfdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: �I (fit) Division of Water Resoull ces,Information Processing Unit,
If water level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
1L Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
/� n above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: f-r 1 2&-ca(Z j construction to the following-
(Le.saga,rotary,cable.direct push,
i
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: 1 24c.For Water Supply&lniection'Weus In addition to sending the form to
``A 43 the address(cs) above, also submit one copy of this form within 30 days of
13b.Disinfection type.l Amount: 0-i completion of well construction tof the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofFnm atenud Quality-Division of Water Resources Revised 2-22 2016