GW1-2021-00394_Well Construction - GW1_20211230

WELL CONSTRUCTION RECORD (GA-1) For Internal Use Only:
1.well.cAntractor Information:
T
I4 ZONES
FRO'I TO I DESCRIPTION
Well Contactor Na fr. 3U fr.
14 336I.
-J r
NC Well Contactor Certification Number R 15,:OUTECASFNG for.matti eased.wetls'O.ttL13+ Rif ticstite
1 FROM t'O DIAMETER THICKNESS MAATERAAI.
1
I l l�Y' IAI 1�V 1 1�1 001
Company Name r� 16: •iVER GA$lKC UR:TItBINC' cothcrmnlldosed toil'
2.Well Construction Permit#:_ )! — I FROM TO DL�METER to THICKNESS MATERIAL
l
List all applicable it-ell construction permits(i.e.UiC.COunn'.State.Variance.ere.) ft. ft.
tt. ft.3.Well Use(check well use): in.
Water Supp1V Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) fr g, in.
industrial/Commercial 0Residential Water Supply(shared) -
irrl ation FROM 'r'O MATERIAL FNIPLACEMRNT NIFTHOD&AMOUN'1'
Non-Water Supply Well: - _
6V_ _
Monitoring ORecoverc fL fL
Injection Well: ft. fr.
Aquifer Recharge 13Groundwater Remediation
19'S�1N1>/GRAVEL PACK'tf.'a liiable)
Aquifer Storage and Recovery E]Salimry Barrier rRo'[ TO 'MATERIAL EMPLACEAIENTMETHOD
Aquifer Test [3Stonnwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20:DRILL NGt LOG attach:additional iheets:ifnecess;!, ..
FRO'T TO DESCRIPTION(rotor,hardness,smUroch e m size,ere)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft �O ft.
01 e-
4.Date Weil(s)Completed: 9 [ Well 1D# O� ft. -3 ft.
;a.Well Location f� t fL NO fL
IJUCnO n04r1 ft. ft. "
Facility/Owner Name Facility IDA(ifapplicable) fl, ft. 3 O
_2 35 Pins- L-04 u Ulv c� Rom/ ft.
Pbysical Address,City.and Zip ft. ft. A►,ry'' rs,`�jtt�"u
21.REN_L%RKS .
x ..::...
County Paz-eel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
(if well field.one Iattlong is sufficient) 22.C 'Fiieati
34'59. ti/39 N N 9° 69, LZ2 W
6.Is(are)the well(s) Permanent or nTemporary Signature of Certified well Contractor Date
Br signing this Ibrm,I hereto•cerrifi•that the ivell(sl was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or '0 with/5.4. C.tC OX.0/00 or 15.4 NC'AC(12C'.0200 Well Construction Standards and that a
If this is a repair.fill out Anown well construction infonnation and explain the nature of the copy ofihis record has been provided io the hell owner.
repair under#21 remarks section or on the buck ofthis(nm.
23.Site diagram or additioual well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells haA=ing the sane 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: I SUBMITTAL INSTRUCTIONS
h/�
9.Total well depth below land surface: 2 ►L (ft.) 24a. For All Wells: Submit,,this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(.&Q00'and'(a.;l(ar) construction to the following:
I 10.Static water level below top of casino: 2� (f[.) Division of Water Resources.information Processing Unit.
Il xnter level is above casing.use"+" 1617 Hail Service Center.Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For infection 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: 1✓ 0 ✓i/ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) j.
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: 24c.For Water Su VIV&1 Iiection Wells: in addition to sending the form to
lk the addresses) above, also submit one copy of this form Aiithin 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Fomi G W-1 North Carolina Department of Errvironmental Quality-Division of Water Resources Revised 2-32-2016
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