GW1-2021-02414_Well Construction - GW1_20210527

L .PrintM11
WELL CONSTRUCTION RECORD(GW-1 For Internal Use Only:
1.Well Contractor information:
7iTa-mison 611bson 14.WATER ZONES
-TR­OM 175- DE�SMFTFUNIII i
Well Contractor Ninic 0 ft, 5d5 ft. 161 I PY> 1706ft Pit
�bq 3 - 5_6 10c, J-kok)oz-J
NC Well Contractor Cvnification Number
IS.OUTER CASING(for multi-cased wells _L_1N�_R(1_f_
apjIc,ble1
FROM TO DA"IITIRt r , MATERIAL RIAL
fr. I ft. I in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit ik 0 00 13 FROM TO I DIAMEITR� TH14rKNESS MATERIAL
whle lion pt-wrw;Ii.e.CIC,Cousin.Slate, l'i,rial (y ft. S
lxtullapldh tc, t)R zi
3.Well Use(check well use): r ft.
I7.SCREFN
ater Supply M ell: FROM TO DIAMETER SLOTSIZF. THICKNESS MATERIAL ATERIAL
AgriculturalAgriculturalE]M��Ipaltpublic ft, ft. in.
Geothermal([ivLun2;Cooling Supply') EKsidential Water Supply(single)
fz. ft. in,
lndustrial/Con-.,.uc,,;a! nResidential Water Supply(shared) -18.GROUT
Irrigation FROM I TO MATERIAL I FMPLACEMENTMETHOD&AMOUNT
Non-Water Supnly Well:
0 '- 1 02C.)
R\4onhorin2 Rccovew ft ft.
Injection Well:
ft. I ft.
Aquifer Recha:=c E)Groundi.vater Reiriediation 19.SAN DIG I RAVEL PACK(if applicabi
Aquifer Storauc zini R"ecovery r1salinity Barrier FROM TO I MATERIAL I E.MPLACEMEN'TMETHOD
f
Aquifer Test nstorm\%ater Drainage ft.
Experimental .,,,:,-,no!ogv [3Subsidence Control
Geothermal i 1.00p) [3-Fracer 120.DRILLING LOG(attach additional sheets if riecessutry)
Geothermal Returns [30ther(explain under#21 Remarks) FROM I TO DESCRIPTION�coloi%hardness.soillivck type. min size,etc.)
ft.
4.Date Well(s)Completed: Well ID# n. i ft. Y6 rN
5A Well Locati-1:
QCU r,ca re y
ft. ft.
Facilitv,O\vner\a:;c Facility ID4(i l'applicable) ft.
ft. �rJ V
Ito &16.ca " Lane, f,_qiV-yiC,--wV oQ9 73o
Physical Address.01�.;lnd Zip ft. i2021
MAY 2 7
U nu;,M� 5&VII
courm Parcel Identification No.(PIN! insel;m"WD Prr'n ssing Unit
ib.Latitude any tong-itude in degrees/ininutes/seconds or decimal degrees-
tPvf R S e r-T.o n
(if\i,ell field.one ki lone isufficient) 22*C
5-3 -, 92"9.3 1 14-1 4 3 1+3 CA A \N-
6.1s(are)the or OTemporary 79-iturco!'Certified 7kell Contractor D41
Hv sr wee#,,i,jorm,I herebY cerq(v thui,ih,-wellf.$)irtm hvervi cons!n:cted, in accordance
7.Is this a repi`-to.!n existing well: [31 es or a wh/5.4 A("ACWC.0100 or l iA:1VACO2C 0200 We//Cwmatenon Slandurds and dial a
/f/lux f_','w! irclIcomirm-mm wforination tind-irhim the itanorcnf thr upr ul du,rc,-tird hu.,hevn lv­-ided it,the I
repujrmn4,r 21 cruet orsm ilit�h,wk o0his,fiii-in. 23.Site diagram or additional well details:
8.For Geoprobc;DP'r or Closed-Loop Geothermal Wells having the same You ma\ use the back of this page to provide additional well site details or well
construction.on:- -I is needed. Indicate TOTAL NUMBER ol'wells cOnstrucittin details. You may also attach additional pages if necessary.
drifted: SI:BMITTAL INSTRUCAJONS
9.Total well depth cetow land surface- 905
-(ft-) 214a. For All NVells: Submit this form within 30 days of completion of well
;Onstrucllon to the Following:
10.Static water A-c!below top of casing;_ _3ot> (ft.) Division of Water Resou i rces.Information Processing Unit,
if truivi,level is ot,, i,w 1617 Mail Service Center.Ra leigh,NC 27699-1617
11.Borehole diameter: (0- 25 (in.)
24h. For•Iniection Wells: In aidition to sending the form to the address in 24a
12.Well constr..,t ci(,ri method: rZo t-a y- above.ai�,o submit one copy of thisi ficirni %,Jzhin 30 days of completion of well
construcu,,n to the following:
(i.e.auger,rotary.c:,ole,iliect push.etc
Division of Water Resources,Underground Injection Control Program,
FOR NVATER� PH.% %VELLSONTY: 1636 Mail Service enter,Ri ileigh,NC 27699-1636
13a.Yield(gpm) .2o Method of test:A)J.coofairlep_ 24c. For NVater Sulan.1%,& Iniectiort Wells- In addition to sending the form to
l3b.Disinfection 1%­I�.('-k 10*1-Aj? the addre:,sicsl above, also submit it the
copy, of this fonil within 30 days of
Amount: completion of well construction to the county health department of the county
Wicre constructed.
FormG\N-I North Carolina Department of Environtucrual Qunlrlk-slit tsion ofWaier Retnjrcel Revised 2-22-2016