GW1-2021-01658_Well Construction - GW1_20210429

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
1.Well Contractor Information:
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14VATERZONES:'i,;.i;'s S�:rriSrls:.,ir:4 fi?,k;�:"•;v �:' t `.0:::F:' (,"
WcUContractorName q FROM TO DFSCRIPME
39
NC Well Contractor Certification Number
A A h -t- PQ . egg\(�9 'i153:0U1ER:GiBIIVG formultita6ed. ells OR73NER .a"lica6le f�� ii;;F.�''
C6,4 /. 1 Y'a S , I/ t. i _nP�O Aeon FROM TO DIAMETER TMCKNM MATERIAL.
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Company Name ���,wiR�® '� >
t.16��E1NER'CASIIVG OR:TUBING: tb"erme121msdano '�Et:as r�>? c'x43d !zri
2.Well Construction Permit#:._ / 3 '7� FROM TO Mbfff ER TmC[ems I MATERML
List all applicable weU construction p—lis(Le.uiG Cmmry,State,Parlance etc.) ft tt. in.
3.Well Use(check well use): & ft In.
Water Supply Well: F1718GREF.N 's'ai: F1„IiK F?d h2 t l r tv„lEi3+ YCu�$..5 ,:E3:s.....r}
FROM ITO DIAMETER swrs z TmcKmEss MATER
Agricultural �MunicipaUPublic
Geothemtal(Heating/Cooling Supply) Residential Water Supply(single) it ft.
industrial/Commercial DResidentiai Water SuPPIY(shared)
�18:-GRODT';�i:S1ei�?ra.'•'Pd')i{t�.e�is�+,t'.I'dot .i�nE�ia'";t7rri�'1<G�;'Ns�:yv5�rit`�
mom •TO MATERIAL' MU"CEM W METHOD&AMOUNT
Non-Water Supply Well: it. ft. 'net"a \ JNP
Monitoring . Recovery. iw ft.
Injection Well: R
Aquifer Recharge OGroundwater Remediation
ft
Aquifer Storage and Recovery Salim" Barrier Ss19:St1NID/GRAVEIrPAl3I MATE 6?alt;u'lsb�;b z>r:Nrtk v<3#
nY FROM TO MATERIAL SIHPLACEaffiITMETHOD
Aquifer Test [3$tomtwater Drainage ft. tt
Experimental Technology nsubsidence Control to a
Geoth=al(Closed Loop) OTracer ;k7AMPEMING1.OG adiietiiiddidun`iililtedts•if""
Geothermal eating/Cooling Retum) Other( lain under#21 Remarks) FROM TO DESCRWnON eoror wtrioetr et)
ZS— fL
4.Date Well(s)Completed: '�-2 O-2) Well ID# 7 5` tt. S—ta Wc�A YM e R
5a.Well Location:
Fec-03/0waerName _ Facility iD#(ifapplicable)
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Physical Address,Ci�d Zip 6
a21tRFdNARK3 r iisY Fbrf 3N �4?a5 xSf ti S r *rwtlYr�w .t? 5+.'S sty
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County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latilong is sufficient) 22.Certification:
6.Is(are)the weli(s)�ermsnent or 1ITemporary Sigma fCetdfied WiftContractor Date
By stgning this form I hereby car*that the tv&(s)mu(were)constructed in6ocordance
7.Is this s repair to an existing well: [3Yes or.G(o tv1 ISA NCAC 0TC.0100 or ISA NCAC 02C:0200 Welt 06mb lion Swmdands and that a
(fdds is a repair,fill out(mown well construction hormatlon and explain the nature of the copyofthts retard has been provided to the isell ormer
repair under#2I remarks section or an the back of this form 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Close&Loop Geothermal Wells having the same You may use the back of this page to.provide additional well site details or well
construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: t_1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:_' / �� ' ( ) 24a.For All We1La: Submit this form Within 30 days of'compiedon of well
For multiple wells/!stall dep a#'diffmW(xample-3®200'and 2®100) construction to the following:
10.Static water level below top of casing: yb t ([t) Division of Water Resources,Information Processing Unit,
Ifwater level Is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 21699--1617
11.Borehole diameter: (in.) . . 24b.For Infection 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) 8 Method of test: :r i / 24c.For Water Supply&Infection 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:_G�42 a-01 Amount:_ 6 Z completion of*well construction to the county health department of the county
where constructed
Form dW-1 North Carolina Department of Environmental Quality-Division of Water Resourcea Revised 2-22-2016