GW1-2021-05588_Well Construction - GW1_20211015

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
i- 'ell Contractor Information:
rI
b&PL Rf< CA-jj_ 14 WATERLOiVES
Well ContmctorName FROM TO OESCAiP7701C
�3a4ft. 1
NC Well Contractor Certification Number 15 OL _.
+TER CASING Ifor multi-eased:walb OR 2....."cable)
FROM TO III, ETER TAICKAFSS MATERIAL
Compam Name 16 iNINER Ggy7NG OR TUBING thermal closed-Isn
2.Well Construction Permlug- FRMI TO I OiAAIEM- TMCkNESS _AtAIIERIAL
list aft aWfrdhle wetl owwr7mWon pernriry d.e.MC,C mrmr.Rare.F!11*mcu,Vic.) 1�� 8- f '. Iku 40 v�
3.Well Ilse(check well use):
Water Sapph Well: 17.Sl a u�To DIAWITR st orM I THICKNIM I 31ATEIUAL
Agricultural nMtmicipal/Public 0 11. Z
. Geothermal(Heating/Cooling Supply) 2fesideniial Water Supply(single) rt, tL la
1ndustrial/Commercial Residential Water:Supply(showd)
18.GROUT
1ni ti011 FRO% AIATEREAL_ VVINACIMTONT_MEMOD&MTO-tt�T
Non-Water Supply Well:
Monitoring, Recovery ft. R.
n ection Vell:
Aquifer Recharge QGroundivater Remedialion fr. ft.
19.SANDiGRAVEL>PACK(if b]e)_ Aquifer Storage mid Recovery 0SalinitV Harrier rRoal T4- nlAtERw : 1rLACEAlExralETlton
3-Aquifer Test [5tnrm�►aterDrainage it: lt.
Experimental.Technology OSubsidence Control ft, ft.
Geothermal(Closed Loop) Tracer as nRuLUNG LOG nttacb mlditieaal sheets ifaaassa
FAOA! TO IMCRI M-1 color,�a�dness.:•iYroe6 to in the eta
- Geothermal:f Heatin Cool in action) Other(ea lain under;;#2l;Remarks) R.
4.Date Well(s)Completed: b 2 l IYei11D# n f+-
5a.Well Location: R`
CIA, \, a n
Facility/Owner Name Facility 11W(if applicable ft. R• P�"
'1t�3 �Ctf�itlttw� � ,.�..�, ��1►�►,,� �= fA e u ..... ,
icaF A City.frulzip 0- R•
21:REA1ARIi5
County ParcelldentificationNo.(PIN) _ Ffj()n prOCSESing Unit
DWR SscC,10
5b.Latitude and loiWtude in degreestminatesisetonds or decimal degrees:
(if►%•ell field,one hunong is sufficient) 2 leaiont
IT.4418Q2 2 ?L a(o% 1 G I �N
6.is(are)thetndi(s)Rfermonent or [)Temporary Tj6tplpe,ofCeriifieaWellContraitor gate
Tit•r,pitig this firnn.l larrehtr cc►r�,ghat tho ut ll(V has Orem)ran.sin(cied in accardwiv
7.is this a repair to an existing well: OYes or Q%o +sfth!iR AC:4C n2['.UIOn m 15A A2 AC t7X'A2U0 rNidl[isa�vrltt7itnr JYwadanls mrd tltot a
If this is a repair,Jill ova knutnr well cmisirvaimi nffbmttatiavrmtd L'rPlaita the notitrr of the cup),aflids itcanl htas been p—ldal ro 09 trzdl auvter.
mmpair render-21 tsma*secvion ar an the hack afthisfann.
Site d"wgram or addidonat eililetaits:
8.For Geoprobe/DPT or based-Loop Geothermal Wdis having the saute You may.use the back of this page to provide additional ci li site details or ivel)
construction,only 1 GW-1 is needed::indicate TOTAL NUMBER of uclls construction details. Vou,thavws�6macli:additionidpegesif.aemsmy.
drilled: 9LiBAli7-IAL lNSTR1ICTlUNS
9.Total well depth below land surfitec: 7 (ft.) 24a.1:or All 11'ellfis Submit this form a•it)in 30 days of completion of well
Aar wuhlple wells list all deluhe T&ffenw(4mmnle-3@2W and 2 tr.1001 construction to the:follot�ing F 4A*
10.Statle water level below`top of easing: _(it.) Division of Water.ResonrrC6 Information Processing Unit
1ts+urerletYlis ahuvr ciasing ine"=" 161L7`Mall Service Center,Ralelgh.INC 2*94617
11.Borehole diameter 00 24b.Far Iuiection'1i'ells: in addition to sendiug,the form to the addiess in'24a
above,also submit ogre copy of ihi fora mithin 30 days of completion of well
12.Well construction method: construction to the fnllmt ing
(i.e.auger,rotary,cable•direct push,etc.) '
Division of Water Resourees 1.16dergr0tmd Injeetlon;Controt Program,
FOR WATER SUPPLY WELLS ONLY: n 1.636 Alai)Service Center.Reletli.NC 21699-1636
13a.Yield(gpm) /`� Method of test: nt� . 24c:For in addition to sending the forth to
l t the sddress(es) above, also submit one dopy of this form within 30 days of
13b.Disinfection type: K~C Amount:. C� completion of ueil construtxion to the coamty health department of the rouRij
where constructed.
Form GW-1 North Carolina Department of Emimnmmtw Qualm•-I)m.10o of Water Pesnu[ces Re.ice.t -ri.�m.c