GW1-2021-05443_Well Construction - GW1_20210503

WELL CONSTRUCTION RECORD(GW-1) --`` For Internal Use Only:
1.Well Contractor Informa�tioonn: _
V�W N P W 14,WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
a ft. ZOO IL
2
2 1 ` ft. ft.
NC WeR Comractor CerfificationNumber y�. 1� IS.OUTER CASING.for:multi-cased weds OR LiI3FR tf a licable)
G�r\D6 2 CUL r `�1Cl I { l t l) �O FROM TO DIAMETER THICKNESS NIATER1AL
u_i ,1 W UG y y�w 1 U,"c ft. ft. ta.
Company Name r 1 A, 2 O�i r
l7 U V 1 I PVC
16.INNER CASING OR TUBING eothermal closed400
2.Well Constructlon Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Conroy,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 I THICKNESS I MATERIAL
Agricultural Municipai/Public ft, g, IF,
Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft. ft. In•
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
h-ri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring Recovery fL ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a Itcbbie
RAquifer Storage and Recovery Salinity Ramer FROM TO 1 MATERIAL EN ,CEMENT s ETFOD
Aquifer Test [3Storrnwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attach additional sheets d necesse
Geothermal(Hearin Coolin Return) Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardncs soiltro k rain s ete
0 ft. '-� ft. &(' Cj i
4.Date Well(s)Completed: 1 ZZ Z Well ID# ft
e, w_n r etfse: ft. ft.
iN►��N� ����� ft. � ;t. t
Facility/Owner Name Facility ID#(ifagolicable) ft ft -
Z C Nn l ci s. 6 K Nam. INC 21521 n ft.
Physical Address.City;and Zip
ft. ft.
W lkl�-5 21.REMARKS
i:iCiln 3fs0ll iUnit
County Parcel Identification No.(PIN) t`r �;
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _(ifwcll field,one lat/long is sufficient) 22.Certification: SVP J R QN V 60L.15 z,`�,_11 H
N W �J
6.Is(are)the well(s)OPermanent or OTemporary Signature of ificd Well Contractor' Date L f.
B}•signiry tlrrs form,I hereby certify"that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or No with 15A NCAC 01C.0100 or 15A NCAC 01C.0100 Well Constniction Standards and that a
rf rhio is n-T, ;' an­r z­.m„an copy ojthis record has been provided to the well owner.
repair under All remarks section or on me back of this form.
23.Site diagram or additional well details:
You may use the back of this page to proride additional vmll site details or well
8.For Geoprobetl"DPTt or Closed-Loop Geothermal Wells having the same
• .--•° . .• .—.,.,-,- .-..�,�.•�. - :, ,•„pqt,,..��;,,,,„r?�„>: -:'uu!rev.:;,,z,;;;,,�.,,.,i!iliennni nw.,.-s;,,i._..-...xry
dried. v SUBMITTAL INSTRUCTIONS
:, -e nr�/e_..{{'!n]eth hrlrtam eanre s:rre�nr• Zqb ,{']t - - __
....... ........... ...., wnstrueUun to the lulluwmg:
10.Static water level below top of casing: ZID (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above caring,use"+^ 1617 Mail Service'Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniectlon Wells: In addition to sendine the form to the address in 24a
10, 1 above, also submit one copy of this form within 30 days of completion of well
11.Well construction method: llll construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
1 Trt]t l!!a TAR C]!h]TT S!]!TT T C t1�R!•, r _ _. -- ,.:. ._ . .'..-.
13s.Yield(gpm) Method of test: �wW 24c.For Water Supply&Iniectlon Wells: hl addition to sending the form to
(� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: ` I 1J completion of well construction t to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016