GW1-2021-07189_Well Construction - GW1_20211006

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WELL'CONSTRUCTION RECORD(GW-I) For Internal Use Only:
1.Well Contractor Information: -
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Well Contractor Name FROM TO I DESCRIPTION
2(� 4 ft. Ile rL M
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NC Well Contractor Certification Number
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A,` Q01V //� && a n`J /OL FROM TO DIAMETER THICKNESS MATERIAL
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Company Name t
)� p�p�) ;x6„1NNER'CASING:OR.TUBMG eotNermalcldse&166
2.Well Construction Permit#: r/ //// !!// FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) fL fL
3.Well Use(check well use): fL ft in.
Water Supply Well: ly5CR1v1� _.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public 0 fl• ft, in.
Geothennal(Heating/Cooling Supply) �esidential Water Supply(single) ft• ft in.
Industrial/Commercial Residential Water Supply(shared) 1&GROUT
Irrigation FROM I TO MATERIAL EMPLAC MENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft Q v 1/r
Monitoring `__'Recovery ft ft
Injection Well: M fL
l Aquifer Recharge QGroundwaterRemediation
i ":19:"�5AND/GRAVEL':PACK;ifa"hcable,"s;. _ .. •,._
#i Aquifer Storage and Recovery IDSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage ft. H-
Experimental Technology OSubsidence Control ft. ft
HGeothermal(Closed Loop) OTracer 20::1)RILLING'L015':attach:addihonalshktr;Jfiiecessa
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,willr ck type,gmin size etc.)
D H. o2 ft 0 50:,C
4.Date Well(s)Completed: Well ID# ft O� H.
ai.Well Location: ft
Boyc' N01re Ba;l4-5 ft. .. ft
Facility/Owner Name Facility ID#(if applicable) ft. rL
/5093 Byf{-�lo 12,J' C14,Y-{ten vco27 'd6 ft ft
Physical Address,City,and Zip ft. ft 0 V�\t
0 (n 5 r!f)n' 2tr REI4IARK5 9
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County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifica
N -70.3'570i W
6.Is(are)the well(s) rmanent or OTemprorary Signa n ctor Date
By signing this form,I hereby certify that the well(s)ivas(were)constructed in accordance
7.Is this a repair to an erasting well: QYes or <0 with 15ANCAC 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 nalure 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:
S.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: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �J (ft.) 24a. For All Wells: Submit this for In within 30 days of completion of well
For multiple ivells list all depths if different(example-3Q200'a�n+dy1Q100') construction to the following:
10.Static water level below top of casing:_��C J (ft.) Division of Water Resources,Information Processing Unit,
1f ivaler level is above casing,use'+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
'12above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: ( 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
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13a.Yield(gpm)_I Method of test: 24c.For Water Supply&Iniection Wells: In addition to sending the form to
i the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HT r Amount: I t" completion of well construction to the county health department of the county
where constructed.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016