GW1-2021-08127_Well Construction - GW1_20211109

WELL CONSTRUCTION RECORD(GW Il For Internal Use Only: -�
1.Well ntractor info mation:
v4. �`���I' 14:WATER ZU1vFS
Well Contractor Name .. FROM TO DESCRIYIION
t/oa- -A �,a ft. 2y2ft. -40py Li few ikc
ft. it
NC Well Coyntractor'CAer/tiSQcationNumbper I
Doty t •v e 1' 1 l i)? l+ROM TO DiAMETEReIIs;ORHICKNE s He AT
l5._ODTERCASINGs formuth-coded
/ L TffiCKNESS MATERIAL
Company Name T� in. R-Zi Vt�
� A` 16::II�iNERGA3INGOIt7UBIgiG'(eotlierma Acre-"oo
2.Well Construction Permit#:t 1 1 u 7 FROM TO_ D CKNESS MATERIAL
List all applicable well construction permits f a UIC CounW,State,irariance,eta) &
3.Well Use(checirwell use): ft. ft. in.
Water Supply Well: kSCREM-,,
AgriculturalDIAMETER SLOTSiM THICKNESS MATERIAL
FROM
im,
Geothermal(Fieating/Cooling Supply) iKcsidential'?Water Supply(single)
in.
Industrial/Commercial Residential Water Supply(shared)Irri 'on ' MATERtitL EMPLACENH?LWr OD&AMONon-Water Supply Well: t ,y_ c_ eel
Monitoring Recovery fnjectionWell:A uifer Rechar a ft.
9 g Groundwater Remediation
Aquifer Storage and Recovery Salini Barrier A9'SAND/GRAVEL PACK°d a"liable
ty FROM TO MATERIAL EMPLACEMENTMETHOD
Aquifer Test oStormwater Drainage ft ft.
Experimental Technology [)Subsidence Control % ft
Geothermal(Closed Loop) Tracer 30:DR(I;LIIVGLOG{attach additional sheets if ne"wi`
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM I TO DESCRItiTtox comas,6nrdaess,samrnek si cram
0 ft. 76' ft. /r
4—Date Well(s)Completed: O-Z-da 1-2(_Wen iD# G M Or1 ft.
5a.Well Location: fL ft
George A. Adwhs ft. ft
Farcility/ crrName / Facility ID#(ifapplicable) % ft.
1'(rS�- !1iR1 i CPA wotl/ftr ie&Pr lid Wdstule4eq t) ft. ft.
Physical Address,City,and Zip z3-04 ft ft
Ashe3!K-Og�Sl-O_V '21c11FAIABIC$ _
County Parcel IdcntificationNo.(PIN) `��
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
INFORMATION WeESS111W
(if well field,one W/long is sufficient) i 22.Certification:
Q0 IN gb.y 77 W
/ Cy'2q-2/
6.Is(are)the well(s)�rmanent or ®!Temporary Signature ofCemfied ntractor Date
By signing this form,i hereby certify that the well(s)was(were)constructed in accordance
7.Is this a.repair to an existing well: E3Yes or 001/v- with ISA NCAC 02C-0100 or ISA NCAC 62C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction h fotmation and o phrin the nature of the copy ofthis reed has been provided to the Fell 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 time 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 INSTRUMONS
9.Total well depth below land surface: )Il t/tl 24a, For All Wells: Submit this form within 30 daysof completion of well
For multiple wells list all depths if diereut(example-3@200'and 2@100) ( construction to the following
f Static water level below top of casing: Jt�C� (ft.) Division of Water Resources,Information Processing Unit,
Ijwater level is above casing,use"+" g t,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1�11 (m.) 24b.For Iniection Wells In addition to sending the form to the address in 24a
12.weD construction method: above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct pushy etc.} construction to the following. I
FOR WATER SUPPLY WELLS ONLY: Division of.Water Resources,Underground Injection Control Program,
l 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) /-i Method of test: lr 24c.For Water Supply&Infection Wells: In addition to sending the form to
OZ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: V completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
• i Revised 2-22 2016