GW1-2021-07788_Well Construction - GW1_20211102

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WELL CONSTRUCTION RECORD(GW-I) For Intemal Use Only:
1.Well C tractor Information:
• =14..WATER ZONES
Well Contractor Name FROM I TO DESCRIPTION
% ft.
NC Well Contractor Certification Number '15:OUTER CASING for multrtase8we71s OR'LTNER'if'a "livable ;f
iobys well pr;IN5 FROM TO DIAMETER I THICKNESS I MATERIAL
Company Name
T' fL 33 ft m.
16.'INNERCASO G'OR•TIIBING eothermalslogi d466
2.Well Construction Permit#: � '3 t FROM TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Count),State,Variance,etc.) IL ft. in.
3.Well Use(check well use): ft. tt. in.
Water Supply Well: 37:$GREEN
_ FROM TO I DiAMETER� SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public fL 11L in.,
NV7Geothermal(Heating/Cooling Supply) ffrResidential Water Supply(single) ft. ft in.
Industrial/Commercial Residential Water Supply(shared) 18.GR0Irrigation FROM TO ,-'MATERIA11C176L "EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. 20 ft.
Monitoring []Recovery ft. ft.
I �`
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Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
419:SAND/GRAVEL PAGK if a livable
Aquifer Storage and Recovery 0 Salinity Barrier FROM I TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage �ft —
ft.
NExperimental Technology ]Subsidence Control ft.
Geothermal(Closed Loop) OTracer 20.DRILL'ING'LOG attach addi6odatsheets:if necessa
Geothermal(Heating/Cooling Return) l Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiltrock e, in size,etc.
U ft. 'Z r�' ft. Diff
4.Date Well(s)Completed: 2 2 I Well iD# 2q It. 10V ft.
5a.Well Location: ft. ft
Faciility/OwncrNamc Facility ID#(if applicable) it.
(� tt 1�
11 11 f� 'owfel Rd
�`fes6A Z1j6h ft. ft.
Ph ical Address,City,and Zip ft. ft.
S�► 0 0 Z2-013 2r.�tEMARIcs 4 - _ ess
Coun " �C,on
tY Parcel Identification No.(PIN) 1'rI �R���i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certificatio
N W
6.Is(are)the well(s)ePermanent or [)Temporary Signature of Certified W; ntactor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or 5?(No with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
If this is a repair,fill out!mown 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: f Gu (fL) 24a. For All Webs: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi,/jerent(exampl(e--31®200'and 2@100� construction to the following:
10.Static water level below top of casing: l J.. (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: 6 1i r (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
1QI fr RO fusV above,also submit one copy of this form within 30 days of completion of well
(i.e,auger,rotary,cable,direct push,etc.). construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: ee y 1636 Mail Service Center,Raleigh,NC 276994636
139.Yield(gpm) Method of test: kl f j 7 24c.For Water Supply&Iniection Wells: In addition to sending the form to
L.� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 1 0-1— completion of well construction to Cthe county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016