GW1-2021-04614_Well Construction - GW1_20210510

WELL CONSTRUCTION RECORD (GW-b For Internal Use Only:
1.Well
''Contractor Information:
6. e e
r' z Sa�d@ s o\ �•.. 14:WATER ZONES
Well Contractor Name pp FROM TO DESCRIPTION
p h IY�a� i 2021 ft 3 r) ft,
4 ft.
NC Well Contractor Certification Number ,Ei�Oj(;;3i7CBt C
e F.�j;pll 15..OUTER`CASING for multi-cased,wells ORLINER ifa 'licable
C//,� Q U �"V FROM TO DIAMETER THICrK�NESS MATERIAL
1 1 v ft QV ft. y/r in. �[/t G �l/G
Company Name v
/� 16 INNER CASING OR TUBING eothermal closed400
2.Well Construction Permit#: 7 S Z FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,Coun)o,State,Variance,etc.) ft. ft in-
3.Well Use(check well use): ft ft in.
Water Supply Well: 17 SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIA►.
:)Agricultural Agricultural 0M rpal/Public 8
6 ft /OC) ft. Y.r in:
:)Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft
Industrial/Commercial 18:GROUT
[)Residential Water Supply(shared)
i Ir i ation_ FROM TO ___MATE, --.EMPLACEMENT METHOD-&AMOUNT - --
Non-Water Supply Well: -- -— - - (, ft D j�J� ro,u.P pur
_Monitoring Recovery ft ft
Injection Well:
ft. ft
Aquifer Recharge Groundwater Remediation
19.`SAND/GRAVEL PACK if a licable
:)Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [)Stormwater Drainage M ft
Experimental Technology Subsidence Control ft ft
EGeothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) I FROM TO DESCRIPTION ccolor,h2rdness,soiurock type,grain etc
U ft f' ft. 13r-°=' G/a 5,'I{ otr- 5-4
4.Date Well(s)Completed: Z 3 Well ID# /v It. 0 B'
5a.Well Location: J ft 3 V ft lv�`-1 I Cd,q dsr Sa N
MA,r(L (_U 01 1 N5 5 ?�t4�a�9�1J"��s,s.v3 30 tt S'o fL i/ C' S C
Facility/Owner Name 9 Facility ID#(if applicable)
t� _G IL
o ". i� R l4-s
P. er LA � y Gid �ro � ZU `� B ft �eo ft //9_tr L
Physical A dress,City,and Zip D ft /OV ft. U'A; r c
_RC&C"o i)3 0010 20 0 3F 2L'ItEMAR1cs h
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) C 22.Certification:
-3'10J q, C)y/ N • S W E4.1
6.Is(are)the wells) ermanent or Temporary SigoatureafCenified Well"Contiact-or
,qv signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or EINo with 15A NCAC 02C.0100 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 of this record has 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
filled' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (] / (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
I
10.Static water level below top of casing: / (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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
n
12.Well construction method: I'1 o�tt� /f s+-4 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 Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 Method of test: /' 1 r �I� 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit`one copy of this form within 30 days of
13b.Disinfection type:_ I Amount- `70 Z completion of well construction to the county health department of the county
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