GW1-2021-06840_Well Construction - GW1_20210419

\ WELL CONSTRUCTION RECORD(GA-1) For Internal Use Only:
1.Well Contractor Information:
T,6.h V, RLt �S 9 a RZ1 14 WATUCZONES
FROM TO DESCRIPTION
Well Contractor Name tt
ft. ft.
ft. ft.
NC Well Contractor Certification Number
1&OUTER:CABING formalt[eased vrlCa UIFLINER.
C FROM HI
TO DIAMETER TCKNESS MATERIAL
r0 S T�/J ft 3 ft. in. �G
Company Name
s1��'1NNERCASIIHGORSTU6ING� .',tli'tlemalFlb`ae8-lob c.
2.Well Construction Permit#: AM Jdf C— FROM I TO DIAMETER . I THICKNESS I
,MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. % in.
3.Well Use(check well use): f,
",-I
Water Supply Well: FROM TO DIAMETER SLOT SIZE TRICE MESS MATERIAL
Agricultural E)Municil%Mblic U fc ft in
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) & fL
Industrial/Commercial IDResidential water supply(shared) i8;GitO[1T,_ ,
ion FROM TO .MATERIAL. EMPLACEMENTMETHOD&AMOUNT'
ft
Non-Water Supply Well: f -S
Monitoring E]Recovery ft ft.
Injection Well:61% fz
_=Aquifer Recharge E)GroumdwaterRemediation }9;Sp/GRet�VEI.PAC&; i" uerb Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPI AC®ffiIT METHOD
Aquifer Test O Stomtwater Drainage fr f
Experimental Technology OSubsidenceControl & fL
Geothermal(Closed Loop) OTraoxa :201t7I;L1NG'Ff)G attiieliddiiIonat=ahabif „ -'
FROM TO DESCRIPTION rotor aalureet
Geothermal eatin Cooling Return Other(explain under#21 Remarks n ere
�l� Q & a ft.4.Date Well(s)Completed: Z — t Well ID# '!/ rT ft. 712 it. ,
It. O ft t
5a.Well Location: '
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t ft.
(Vlos�c k�dfd;., cc..11 C
Facility/Owner Name 0' Facility ID (if applicable) fro ft.
ft. ft. q��
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7—
Physical Address,City,and Zip Z�Z L 7 ft ft
.J3�'fsZ /� 2f'RFMARKSx:
p/ g
County Parcel Identification No.(I'Do r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/longsiis sufficient) C 22.Certification:
N lJ G a W 4/
SignamofCertifieHComrctor Date
6.Is(are)the weil man(s) erent or Temporary a
By signing this form,I hereby certify that4he wells)was(were)constructed in accordance
7.Is this a repair to nn existing well: D Yes or nmo with ISA NCAC 01C.0100 or ISA NCAC 02C.02W Well Construction Simdands and that a
If this is a repair,fill out known well construction information and explain the nature of the copy ofthis record has been provided to the ire/1 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: 2013 00 249.For All Wells: Submit this form within 30 days of completion of well
For muhtple wells list aq depths ifdt,(jerent(example-3®200'ond2@1W) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwaterlow/is above caging we"+" —� 1617 Mail Service Cooler,Raleigh,NC 27699-1617
11.Borehole diameter: �� (in.) 24b.For Iniecdon 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: /' ei 4.4 f-y construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Infection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center-,Raleigh,NC 27699-1636
13a.Yield(gpm) �' Method of test: ^ 24c.For Water Sunnly&Iniectio Wells: In addition to sending the form to
r,01 the address(es) above, also submit;one copy of this form within 30 days of
13b.Disinfection type: 'ti Amount:-2S 07 , completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources ` Revised 2-22-2016