WI0100594_Geothermal Well Construction Record (GW1)_20200907

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
�taWl�S --R, �A�i�Spn
WeO Comrecmr Name
NC Well CormanorCertifcation Number
t
Company Name
2. Well Construction Permit#: VV) 0) O
List all applicable well croltVrudion permas (r.e. UIC County, ffime, arimlce, dcJ
3. Well Use (check well use):
❑Agricultural OMunicipaVPubiic
❑Geothermal(Heating/Coolmg Supply) CIResidential water
❑Indmtrial/Commercial OResidential Water
OAquifor Recharge
OGroundvvater Remediatiou
OAquifer Storage and Recovery
OSalinity Barrier
OAquifer Test
OStormwater Drainage
OExperimental Technology
OSubsidence Control
eothermal (Closed loop)
OTracer
OGeothermal (HeatinelCooline Return)
OOther(e:mlam under#21
Remarks)
4. Date Well(s) Completed: Well
S& Well Location:
nn
Faerlity;AD 'nerName
Physical Address, City, and Zip
mo,con
County
Parcel Ide reification No.
5b. Latitude and lorngitude in degrees/miaotes/seconds or decimal
(ifwel] &Id, one latrong is sufficem)
6.Is(are) the weti(s): OPermavent or OTemporary
7_ Is this a repair toanexisting well: ❑Yes or 'hNo`
lfiha r, is a mpaifdl am known well cmutradian informarlon.inderp/am the a
repair tinder rill remarks section or on the back ofthisform. I
8. For GeoprobeMPT or Closed -Loop Geothermal Wells t
construction, o� 1 GW-1 is needed. Indicate TOTAL NUM
dtilW'
9. Total well depth below land surface: M8,
Formuftiple wells list all depths lfdiffermt (trample-3@200-aad2C
10. Static water level below top of casing:
lfwater lerel is above ensbrg use "'"
ll. Borebok diameter. (D ..le^t (i1L)(S
12. Well construction method: A i R I t�.ot74((I )
(Le. auger, rotary, cable direct post, etc.)
FOR WATER SUPPLY WELLS ONLY: AA
13s. Yield (gpm) n Method of test- 141 R
13b.Dislakctontype:V)Tln TPAICi-5 Amount:
For Internal Use Only:
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22. CertiBcaton:
U'7 _orb
ofCartified WenCoWmclor Date
''+.'•� slgrarglhafrem, lberebymnifylbm lhewelf(s) war(wen) cvn.6rudedm a anrdavzcc with
^ NCAC 02C.0100 or ISA NCAC 02C.0200 Well Caraslrudim Srmrdmds mid thin a mpy
o R1 �Yfrhfs ranrr!(nsbeen providedto the well owner.
23. Site diagram or additional well details:
no _ Yoy'rocay, use the back of this page to provide additional well construction info
.. - (add'See Over in Remarks Box). You may also attach additional pages if necessary.
Submit this GW-1 within 30 days of well completion per the following:
24a. For At Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit, 1617 hfSC, Raleigh, NC 27699-1617
24b. For Injection Wells: Copy to DWR, Underground Injection Control (TUC)
Progmrq 1636 MSC, Raleigh, NC 27699-1636
24e, For WaterSuooty and Oven -Loop Geothermal Return Wells: Copy to the
county envhonmental health department oft: county where installed
24d. For Water Wens mduci over 100 AP: Copy to DWR, CCPCUA
Perms gram, n 1
Form GW-I North Carolina Department of Environmental Quality -Divisors of Water Resources Revised 6b2018