GW1-2021-00560_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Infor=tton:
14.WATER ZONES
Well ContraetorName FROM TO DIMCRI]MON
NC Well Contractor Certification Number
�1 13:OUI'ER'CASnVG' 7'rnDIn;C95ea sveirb OR LIIYER tta Hcable
I _ I/ FROM TO DIAMETER TRICKNES6 MATERIAL
��f � 5
ft- I I QV ft- in. D _
Company Name 16.INNER CASING ORTUBIN eothermal dosed-loop)
2.Well Construction Permit : FROM TO DLI dMR TMCKNESS MATERIAL
List all applicable well construction perntits(i e.UIC,County,State,Variance,etc.) R• R• P.
3.Well Use(check well use): ft' ft. 1O `
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT STYE THICKNESS MATERIAL
Agricultural cipal/Public 0 ft, ft, in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft, ft, rn.
Industrial/Commercial inResidential Water Supply(shared)
IS.GROUT
Irrigation FROM TO ATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft fk �t,rt r riI
Monitoring _ 11mvery tl. ft. �c L
Injection Well:
fk
_ Aquifer Recharge [(_Groundwater Remediation
19.SAND/GRAVEL PACH >f ucable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage n• R•
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) E3Traccr 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal eatin Coolin Retum) _;Other a lain under#21 Remarks FROM TO DESCRIPTION color hardness,sonhnck sire,eta
ft. f.
4.Date Well(s)Completed: (o 21 Well ID## ft. 'L
ga.Well Location: // ft. ft
S#!✓! �q�/QG e
Facility/Owner Name Facility M#(if applicable) ft. fL
P.
ft. ft. Uk U 2 2
Physical Address,City,and Zi ft' (L
1
PIC l k*Jn 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude In degrees/minutes/seconds or deciml degrees: �/ / {� 1/41 o to
(if well field,one lat/long is sufficient) 22. ca' n: 01 4 ('
N -�7�j- 223 7 / W
6.Is(am)the well(s)Qfernument or Temporary Sign of Certified ell ctor Date
By signing this form,I hereby certify that the wall(s)war(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or �To with 15A NCAC 02C.0100 or 13A NCAC 02C.0200 Buell Construction Standards and that a
If this is a repair,fill out known well construction informatlon 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 i GW-1 is needed. Indieate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
9.Total well depth below land surface: 24a.For Ali Wallst Subunit this form within 30 days of completion of well
For multiple wells list all depths tf different(example-3Q200'and 2@ 100 1 construction to the following:
10.Static water level below top of casing: Z 4- (ft.) Division of Water Resources,Information Processing Unit,
If water level Is above casing,use"+- 1617 Mail Service Center,Raleigh,NC 27699.1617
I
11.Borehole diameter. 674 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
/J �� above•also submit one copy of this form within 30 days of completion of well
12.Well construction method: �` construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resonreea:Undergmund I action Conte-1 ProWnm,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 522 Method of Wst 24c.For Water Sun&&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:JI
rAmonntz 9 ou n e e-6t 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 Revised 2-22-2016