GW1-2021-02112_Well Construction - GW1_20210709

" �;;P�lnt Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1 ell Contraeto ormaHon:,, 1
Ss7� °.14.WATER'LONES'
Well Contractor Name ENED FROM TO DESCRI;MON
9_YR ,AN
It. ft.
N Well Contractor Certification Niber JUL O 9 2021 'A&;OUTER'CASING"for matt€casei7 we➢s'r. INER !cable ` '
�� � FROM TO DIAMETER TIDCIQM MATERIAL
' ft, ft. ', ia.
Company Name infoimation
DW R SeCtlOn I INNER CASING OR T[IBINC.''eothermall drisedN `
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) N•s- ft. 00 ft in. 56 l (,(.(� �/G
It.
Well Use(check well use): ft. f ra �f 1 V
lGeothermal
er Supply Well: A7.SCREEN '. ;,..
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ricultural Municipal/Public I OC)fL '�o ft- io 02-0 CCI 14 -) U C,
othermal(Heating/Cooling Supply) Residential Water Supply(single) l it tL is J 11
ustriallCommeroial Residential Water Supply(shared)
l8.GROUT '
FROM TO MATE EMP CEMENT METHOD&AMOUNT
Water Supply Well: fL t3 tt kL l41nitorutg` - `_ DRecovery _. ft. ft.
tion WeB: fL ftuifer Recharge Groundwater Remediation19:SAND/GRAI>EL PACK if a ticableuifer Storage and Recovery Salinity Barrier FROM TO MATE EMPLACEMENT METHOD
uifer Test DStormwaterDrainage q'J ft• Q0 ft• S %CAperimental Technology Subsidence Control ft. ft.
othermal(Closed Loop) E)Tracer 20..DRILLING HAG attichadditioaalsheetsM '(HeatingtCoolitig Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock etc.
ft. IL
4:Date Wells)Completed: Well ID# ft tt
5
ft. fL
yVW�.. 5►S01q/� ... !g,ft 416,V%CS=
Facility/Owner Name Facility (if applicable) fL tL
` ft. ft
ysical Adrkess,Ci , Zip ft. ft.
lam' Qy` ';21:REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,oonne lat/long is sufficient) n G 2 Certificatio
�3 �D��I�D , N -77,d�J��� l W
6.Is(are)the we0(s) ermanent or 13Temporary SignaW of Certified Well Contractor 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: QYes or MWo with 15A NCAC 01C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a
If this is a repair,fill out known well construction informa(ion 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 thisform.
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.
filled' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 Z 00 24a. For Ali Wells: Submit this form within 30 days of completion of well
For multiple wells list a!1 depths ifdp Brent(example-3@200'and 2@700� constructs
on to the following:
10.Static water level below to of casing (� ) Division-of Water Resonr• tResources,Information Processing Unit, .
If water level is above caring,use"+' t l 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter - (m.) 24b.For Iniection Wells: in addition to sending the form to the address in 24a
aboe,also submit one-12.Well construction method: construction to the following:.yof tliis'form within 30 days of completion"of well
(i.e.auger,rotary,cable,direct push,etc.)
FOR `
Division of Water Resour
WATER SUPPLY WELLS ONLY �" nderground Injection Control Program,._..
_ - `. 1636 Mall Service Certer,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test 24c.For Water Supply&Injection 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: Amonat: )1�. c5 completion of well construction 6 dw t 001 twe counte countyy
where constructed.
Form GW_1
Form GW-1 N&W&fxyffiUq5JRff aA eN,W Eoron n�al'Qiality-Division of Water Resources
Q ty-Division of Water Resources 2@I6