GW1-2021-00026_Well Construction - GW1_20211109

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WELL CONSTRUCTION RECORD(GE-1), For Internal Use Only:
1.Well Contractor Information:
ItRf�I1 C71 iTM 14.WATER ZONES .
WellContracto�rNvame FROM TO DESCRIPTION
21 ft.
NC Well Contractor Certification Number / MOUTER'CASDVG' rmum easeA wefts OR LIIVER Ira Usable
:FROM TO DIAMETER�• THICIWM MATERIAL
Company Name /
I&DYNER CASING OR DIG(eothertltal closed-loop)
2.Well Construction Permit : FROM I To I DIAMETER I THICKNESS MATERIAL
List all applicable hell construction penults(i e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft• ft. in.
Water Supply Well: .1T SCREEN
FROM TO DIAMRTBR I BLOT SM I THICKNESS MATERIAL
Agricultural DMunicipal/Public 0 ft, ft. in.
Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft ft, In.
Industrial/Commercial E3Residential Water Supply(shared) 1B.GR4DUr
Irrigation FROM TO MATERIAL EMPLACEMENT METKOD&AMOUNT
Non-Water Supply Well: ft AV
ft �'
Monitoring __.Recovery ft. ft.
Infection Well:
Aquifer Recharge Groundwater Remediation f
Aquifer Storage and Recovery S Barrier 19:SAND/GRAVEL PACH d licable
l9 ry almtty FROM TO MATERIAL I EMPLACEMENTMETHOD
Geothermal
Aquifer Test OStormwater Drainage ft• ft•Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRII,LIlVG LOG attach additional sheets if n Heatin Co ling Return) ClOther lain under#21 Remaricc FROM I TO DESCRIMON color,taudn soil/nick ow,grain size,etc
ft.
ft. 19V C`
4.Date Well(s)Completed: •?l Well um ft. 'Isft.
Sa.Well Location: 2=9ft' 41190
ft. Ono
NOV
Facility/Owner Name Facility ID#(if applicable) ft. ft.
fL ft. i n SEG I IC)N
Physical Address,City,and Zip ft. ft (lt►°
21.REMARKS .
County Parcel Identification No.(PIlV)
5b.Latitude and longitude in deglees(minutes/seconds or deciml degrees:
(if well field,one lat/long is sufficient) 22. n:
36.S2797 3 ' 79.7V 99-cm w
�0/1C ?,// �
6.Is(am)the well(421rernment or OTemporary ignatura Certified Weli Co r Date
�,� By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an ertisting well: nYes or with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out ktrown 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 bark of thisform.
23.Site diagram or adttttional 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 ofwells construction details. You may also attach additional pages if necessary.
drilled: �t
9.Total well depth below land surface: �[�[✓ (fL) 24e.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tf different(example-3©200'and 2Qa 100) construction to the following:
10.Static water level below top of casing: Z (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. F'O uy$ (in.) 24b.For Iniec ion Wells: In addition to sending the form to the address in 24a
above,also submit one copy of,this form within 30 days of completion of well
12.well construction method: g a�%4 construction to the following:
(i.e.auger,rotary,cable,direct pitch,etc.)
Division of Water Resources.Undergnovnd Inijeelion Control A- ,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) �� Method of tPs� /O u r. 2O,. .7.f.For Water SnDDty&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: 1-17 Amount: /G DLL ,Z « completion of well construction to the county health departrnent of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016