GW1-2021-01013_Well Construction - GW1_20210419

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
T1.Wq]I,Contract rInfor '�_ j
L/ 44.WATER-ZONES x
a Well Contracto Name :, FROM TO DESCRIPTRN
r^5� ,�
,�"� ft. ft.
t 021 ft. ft.
NC W C ractor,CpppeerrtificatioZ��
be P R 15 OUTFdf:CASING:[or mul welt"OR 1 IIVER a' heable ^'y
�( OM TO D v/ �Sl ft. ft. in
Company Name - � ' �
// �'�u{��•" '16'1NNEttT:ASING;UR-TUBING thermal=tluscdaoo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits 6.e.UIC,County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft. ft.
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Water Supply Well: FROM TO DIAMETER SLOrSIZE THICKNESS MATERIAL
Agricultural [Municipal/Public U & & is thermal(Heating/Cooling Supply) [)Residential Water Supply(single) & &
hidustrial/Commercial [Residential Water Supply(shared)
-lti.G'BOOT ,.
Irrigation FROM TO MATERIAL METHOD AMOUNT
Non-Water Supply Well: & fL r
Monitoring ;Recovery & ft. D
Injection Well:
Aquifer Recharge [Groundwater Remediation & IL
-i9-SAND7GRAVEL:FACK, a•" cetile
Aquifer Storage and Recovery [Salinity Barrier FROM TO MAT MIAL EMPLACEMENT METHOD n
Aquifer Test [StormwaterDrainage & &
Experimental Technology [Subsidence Control & &
Geothermal(Closed Loop) [Tracer 20;=DRII.LWG'LOG; tmeti addidiii t:�Jifi&s:lfoeeess
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Geothermal(Heating(Cooling ( FROM TO D ON color hard soWrock eta:
(Heatin Coolin Return) Other lain under#21 Remarks d& &
4.Date Well(s)Completed: 7 "�'y Well D)# fa ft.
Sa.Well Location:
�T ft ft 5
Facility/Owner Name Fac #(if licable) ft. ft. -
l� le
Physical,Address,City,and Zip ,
tt ft
County 7 t �L Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwefl field,one lat/long is sufficient) % i 22.Ce Cation:
��/a �50 'z �IY15:I/W�r W - 1/ nil
6.Is(are)thewell(s) rmanent or [Temporary 5ignat —6 1 Date
� By signing this form,I hereby cen*that the well(s)was(were)constructed in accordance
re 7.Is this a pair to an existing well: D Yes or;gr. with 15A NCAC 02C.01W or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy ofd*record I=been provided to the well owner
repair under#21 remarks section or on the 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
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �fl L� P 00 24a.For All Wells: Submit this'form within 30 d
For rmtltiple wdls list all depths tfdifferem(example-3Qa 200'and 2(a�I00ry days of completion Of well
construction to the following:
10.Static water level below top of casing: .�� (ft.) Division of Water Resources,Information Processing Unit,
Ifwarerlevel Is above caning,use` 1 161.7 Mail Service Center,Raleigh,NC 276"-1617
11.Borehole diameter: '� y (in.) a 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: T construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: `,i 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gprn)1P4iV Method of test � /[0 24c For Water Supply&Iniection Wells: In addition to sending the form to
dr�— 1 the address(es) above, also submit one copy of this form,within 30 days of
13b.Disinfection type: Amount: / completion of well construction to;the county health department of the county
where constructed.
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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