GW1-2021-04418_Well Construction - GW1_20210811

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contr ctor Information:
OU Ca
014.WATER ZONES
FROM i0 DESCRIPTION
Well Contractor Name ft. ft.
' ft. ft.
N !yell Con ctor Certification Numbzr 15.OGT'ER CASING for multi-cased wells OR LINER if a Itcabk
r�1► / �lf"y' � ��rt/� FROM TO DIAMETER Tnf� 5 MATERIAL
11i711 66 it `I ft. ? in. (`/,
Company Name 16.INNER CASING OR TUBIN (geothermal closed-loop)
2.Well Construction Permit#: FROM L TO DIAMETER THICKNESS MATERIAL
List all applicable cell construction permits(i.e. UIC,County.State, Variance.etC.) ft. ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM ro DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Q unicipal/Public 141 ft. �j`) ft. in. ,fo
Geothermal(Hcatingicooling Supply) Residential Water Supply(single) ft. ft. in, `V V
lndustriaVCommercial Residential Water Supply(shared) 18.GROUT
Irri anon FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: tt.
Monitoring Recovery
Injection Well:
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Dsalinity Barrier FROM To MATERIAL E\tP ACEMF.NT METHOD
Aquifer Test DStormwater Drainage 141 ft' I U ft-
m t i _Qr
Experimental Technology OSubsidence Control ft. I ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color.hardoess,soil! k type,grains"etc.
Geothermal(Heating/Cooling R'et(um�) Other(ex lain under#21 Remarks) ft. ft.
rvi
4.Date Well(s)Completed: �`^ Well ID#
ft. 40 ft. C I Lxtm
5a.Well Locatio
ft. -7 0 Ct. /z
Facili iD# tt licabky ft• V ft' V` /
Facilityr erName 4' t•�aPP
Physical Address,City,and Zip rid'{
01 15(a 21.REMARICSJI/
VJ1�F1 { SJ V ✓1 ' - `�y�y �Jtypn
County Parcel IdentificationNo.(PIN) Q
5b.Latitude and longitude in degrees/rninutes/seconds or decimal degrees:
(if well field,one lavlong is sufficient) 22.Certification:
N W DMA,� CZ0 U
Srenaturc of Certified Well Contractor Date
6.Is(are)the well(s) Permanent or Temporary
Br signing this(orm,I herehy c•erlifi'that the is-ell(s)was(were)constructed in accordance
7.is this a repair to an existing well: E]Yes or Oar<eo mth 15.4 NCAC 02C.0100 or 15.4 NCAC 02C.0200 Fell Construction standards and that a
ifffi&is a repair,,/ill out known well construction information and explain the nature al-the copy of chic record has been provided to the well maser.
repair under#21 remarks section or on the back c?f 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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: ((ff SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �V 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ffnli ferent(example-3(d,200'and 2Aa100) construction to the following:
10.Static water level below top of casing: 3y (W Division of Water Resources,Information Processing Unit,
tf water level is above casing,use i+" 1617 Mail Service Center,Raleigh,NC 27699-1617
y
11.Borehole diameter: (In.) 24b.For Injection 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: M �Q � 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 Senior Center,Raleigh,NC 27699-1636
13s.Yield(gpm) t OU Method of test: 24c.For Water Supply&Iniection Wells: In addition to sending the form to
Vl�1'
2 the address(es) above, also submit: one copy of this form within 30 days of
13b.Disinfection type: h Amount: 3o2 completion of well construction to he county health department of the county
where constructed.