GW1-2021-06579_Well Construction - GW1_20211029

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
1.Well Contractor Info r on:
14.WATER ZONES: k.
Well Contractor Name FROM TO I DESCRIPTION
ft. 64 It rt- C�Im•�t-
fL ft
NC Well Contractor Certification Number
15.'ODTERCABING for'malh-caseii�wells iOR_LINER' lies6le"
�bys w��' T�r�'I�,�� FROM TO DIAMETER T�CKNESS MATERIAL
Company Name 1 1 It. 30 IL 1 6 .in. SDR'21 r,/
2 C �� 16 ILMR'CASIiNG.ORTUBING(eothermal clas'eldrloo
2.Well Construction Permit#: o Q FROM TO DTAME IER THICKNESS I MATERIAL
List all applicable well construction permits p e.UIC Count;,,State.Variance,ere) f ft. in.
3.Well Use(checit well use): ft EL in.
Water Supply Well: 17:SGREEN
FROM TO DIAMBrER SLOT SIZE THICIO(M MATERIAL
Agricultural crpal/Public ft ft in.
Geothermal(ffcating/Cooling Supply) Rcsidential'Water supply(single) ;• ft ft. in.
Industrial/Commercial DResidential Water Supply(shared) i8i GROUT
7hrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: G it. 2 - & -pi IA- i pumped
,Monitoring Recovery ft, ft.
Injection Well:
fL ft
Aquifer Recharge oGroundwaterRemediation
19.�SAND%GRAVELPACIC "a 'llceble
Aquifer Storage and Recovery [I Salinity Barrier RROM TO MATERIAL EMPLACEMMTMETROD
Aquifer Test 0stormwater Drainage ft. ft.
Experimental Technology oSubsidence Control ft ft.
Geothermal(Closed Loop) OTracer 20.DRELLING LOG attach additional sheets if necessary)
Geothermal(Heatin Coolin Return Other lain under#21 Remarks) FROM To DESCRIPTION color,hardness,sovmck t in sim etc.)
Q G n' 25 ft• pvpf burden ravel
4.Date Well(s)Completed..-`�?"Z Well]ID# 2(, ft. 200 ft' cc citlipe
Sa.Well Location: ft. ft.
Thal4cis 1-ynch &
Facility/Owner Name Facility ID#(if applicable) ft• ft. ''`a
In/'Ps�' M�(� Gf«k�1.3 rail�s on LrFt Warrntsr�lle ft ft' � ��
Physical Address,City,and Zip 'Cgrjq; 1t ft
Ash 02113-001 21:
County Parcel Identification No.(PIM
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W G'G7- -.I
6.Is(are)the wen(s)&Kermanent or OTemporary ciratan ofCettified Well Contractor Date
By signing this form,I hereby certify that the i ell(s)was(were)constructed in accordance
7.Is this a repair to an eAsting well: 13Yes Or M<O with 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Constuction Standards and that a
If this is a repair,fill out known well construction information and explain the nature ofthe copy of this record has beenprovidedto the n ell 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 I
9.Total well depth below land surface: 7—Q0 (fW 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(erample.3t200'and 2©1001 construction to the following:
10.Static water level below top of casing: 30 (ft) Division of Water Resources,Information Processing Unit,
Ijxtrter level is above caring,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: Il$ (m.) 24b.For Infection Wells: In addition to sending the fora to the address in 24a
,�•r n {- above,also submit one copy of this form within 30 days of completion of well
.12.Well construction method. 1 110_hy construction to the following-
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Undergropnd Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: //�� 1636 Mail Service Center,Raleigb,NC 27699-1636
13a.Yield(gpm)7 Method of test: /Z 1 r Li F lh 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this foam within 30 days of
136.Disinfection type: Amount: Z. completion of well construction to the county health department of the county
where constructed.
Form GW-1 Notch Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016