GW1-2021-07429_Well Construction - GW1_20210921

WELL CONS'TRUCTTON RECORD(GW-1) For Intemal Use Only:
I.Well Contractor Information:
E.tiC/1']b o(t -14:WATER°°ZONES x'_t
FROM TO DESCRIMONI i
Wen Contractor Name '
ft. I-� ft /,"
i s 2 3 A ft. p ft
NC Well Contractor Certification Number fS.OUT-ER CASING`for mulft=cas e s OR LMR u llcable
r FROM TO DIA11 Tml7CD1ESS MATERrAL
1 1 l�.Je[l l ) yo �G
Company Name
ib.INNER-CASING OR TtJIiIlYG eathermal dosed-loo
2.Well Construction Permit#. PW12ZQ r110009_ FROM I TO I I)LO SM I TE90O ESS YI MATERIAL
List all applicable well construction perniits(Le U1C, o lfnrfanee etc.) ft. ft. in
3.Well Use(check well use): ft ,_R' l in
Water Supply Well: <,17 SCREFly
FROM TO DLtML-rER Sr.OT SrZ£ TmCKNESS ,i4IATERiAL
LOGeotbermal'(HeatinglCooling
OMunicipal/Public tt t. m• �Q
Supply) *esidential Water Supply(single) ft. &ornmercial OResidential Water Supply(shared) .Yg.GRODT OWells>100,000 GPD FROM Ta MATERIAL pn1A ht�OD& oVNTDPF13 Well: D ft A ft
OMonitoring ElRecovery fb IL
Injection Well: ft. fL
OAquifer Recharge OCrroundwater Remediation
❑Aquifer Storage and Recovery OSatinfty Barrier R�arm/GRTO-_ Mif AT a EMPLACI MM£NT H EMOD
OAquifer Test ❑Stormwater Drainage !2a & oft-
OExperimental Technology OSuhsidenee Control fL fL
OGeothetmal(Closed Loop) OTracer 20.DRtMLING LOG aftnclr addihorial sheets if Ogees
OGeothermal(HeatingtCooling Return) OOther(explain under#21 Remarks) FROM TO DESL"RIPTION color,hardn IoiOraek �, a sin ac
�} ft. ft
4.Date Weil(s)Completed:7'1 Z Well 1D# ft ft. a
Sa.Well Location: fL' ft
'Fa
/Owrier Name�T Facility lD#(if applicable) RIx
it ft
Physical ddreis.City,and Zip QR R
. �}•-� o �: �,l 1�?/ zi REMARlts
h County Parcel Identification N'o.(PlN)
� tC(t�t1p 5gE✓tlpr
5b.Latitude and longitude in ilegreestminutestseconds or decimal degrees:
(if�w,ellll field,o{ne lattlo/n�g is sufficient) //� yy /
7;zt'-4- �P-A0
N of fled Well Contractor Date
6.Is(are)the well(s):�i Permanent -or ❑Temporary \
signing thfrform,l herebycerYrfy that the well(,)was(were)canstructed in accordance with
7.Is this a repair to an existing well: OYes or 15A NCAC 02C.0100 or 13A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature ofthe of this record has been provided to the weft comer
repair under#21 remarkr section or on the back of thisform-
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 construction info
construction,only I GW-1 is needed, Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS;.
9.Total well depth below land surface: �� � (f t) Submit Yhls GW-1 within 30 days of well completion per the following;
For multiple wells list all depths ifd perent(example-3 r@200'and 2@100)
24a. For An Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft)
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifuwter level is above casing,use"+"
11.Borehole diameter: Z. (m.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: M 4A d rd
- ,For Water Suppty'and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) �- county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Cop
y to DWR,CCPCUA
13a.Yield(gpm) 1( Method of test- t"1 l 9 Permit Program,161-1.MSC,Raleigh,NC 27699-1611',
? 1;. i;irsfc:cE*ems type:__._ !t!__ ._. Amount: / w_