GW1-2021-00336_Well Construction - GW1_20211220

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14,WATER ZONES
Well ContgrName�3 FROM TO DESCRIPTION� g►eft. 9 it.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for malti-cased'welis OR LINER if a` Usable
\ ,-�-(\may ,!1 11 1 FR M TO DIAMETER THICKNE�S(S MATERIAL
�J,(J� r 1 fL g fL a � `L u
Company Name _
�— ,! 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: h\P C)� �, e�V FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
;_ Agricultural OMunicipal/Public Oyj ft. Cl ft. in. C1 V t�
SC An 4 P
_,Geothermal(Heating/Cooling Supply) sidential Water Supply(single) ft. ft. in.
Industrial/Commercial _)Residential Water Supply(shared) 18:GROUT'"
Ini ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. C,
Monitoring Recovery
Injection Well: �lr
ft. ft.
Aquifer RechargeGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
'-
Aquifer Storage and Recovery EISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
__:Aquifer Test �J I Stonnwater Drainage � t. it. �
Experimental Technology E]ISubsidence Control
B
Geothermal(Closed Loop) [MITracer 20.DRILLINGLOG(attacli additioitil seets ifn&6ssaGeothermal(Heating/Cooling Return) I IOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rockty e, rain size,etc)
^
Wxo��Dwelll]D#
4.DateWell(s)Completed: a ft. ft. v
5a.Well Location: `� p Cs ft. 3 ft. Lo ._
1\ oY�\A �1 oY 1�--'� W ft. UV ft. imck.,�r do LI
Facility/Owner Name Facility ID#(if applicable) O . ��^' ft. 1�
V LLCA ICb 1PV�, �.�. g J, ft. l�
Physical Address,City,and Zipt.
L S'C0.X1 ,
?C l_r 21.REMARKS
County Parcel Identification No.(PIN) ur 2.0 2021
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N y (a
a , ac�X4 N �l4° n113�� w
te
6.Is(are)the well(s) Permanent or OTemporary Signature of Cert' d well Contra or Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction informationXndexplain 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: 9 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100D construction to the following:
10.Static water level below top of casing: 3 (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: (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: 1Ml,Jld ��))�_�-� 11-,A above, also submit one copy of this form within 30 days of completion of well(i.e.auger,rotary,cable,direct push,etc.) J
construction to the following:
Division of Water Resources,!Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) _ Method of test: �Yr 1 M 24c.For Water Supply&Iniection Wells: In addition to sending the form to
1 'c the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: T completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resource`s Revised 2-22-2016
i