GW1-2021-02546_Well Construction - GW1_20210805

WELL CONSTRUCTION RECORD(GW-1) For internal Use only:
1.Well Contractor Information:
14.WATER ZONES 0 DESCRIPTION Well Co—mraotor Na;nr
q053—
NC Well Canrtctor C'vniiicatirnt 15.OUTER CASING(for TE1iiAc,,gd", Its,TOB�U," Iila a"e'P 'iS-
-FROM TO T, .9 1IMMAL
AwD So 44c ft. in.
Company Name I I
16.INNER CASING OR TUBING eeother at closed-loop)
x MATERIAL
. ,Mother
2.Well Construction Permit iq: 0 45 FR \1 TO ETER i THICKNESS
ft• in, bit z V C
3.NVell Use(Check well Use): ft. ft. in.
W 17.SCREENater Supply%\ell: FROM TO iA**IETER SLOTSIZE THI 'KNESS NIATERIAL
Agricultural [3m Icipal/Public ft, ft. in,
Geothermal I Hc,:tun2,Cooling Supply) Zu,i, I
lu esidential Water Supply(single) f-. ft. in.
IndustrialJCon.-.,no.,,:L! [DResicleniial Water Supply(shared) I&GROUT
Irrigation I FRONI I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
"on-Ni'ater Supply Well: o f­ 1 070 fl. xaah4e.
Monitoring . ft. ft. I.
Injection Well:
ft. ft.
_JAquifer Recha;—, pGroundwater Remedialion I—
:)Aquifer Storagv mind Recovert, nSalinity Barrier FROM
SANDIC.RAVEL PACK ffalatilicable)
FROM TO T MATERIAL ENIPLACENIE,,rrmETHOD
:lAquifer Test nstorm,ater Drauiagc ft.
Experimental 1:cnnok)gy [3SL1bSidCnCe Control ft.
Geothermal i.00p) nTracer 20.DRILLING LOG(attach additional sheets ifnecessaiT)
Geothermal(l­!�­_i:i:-.g,;Cooling Return) r3Other(explain under#21 Remarks) FROVI TO I DESCRIPTION(color.,hardness.soilfrock tw.,linin size,etc.)
Ito OVEA-b LA Ydt,!J
4.Date Well(s)(ompleted:141—JI Well ID4 rom
5a.Well Locati:.j:
W
Girpi Kitlmas4o
cat:
FacilitN14%ner'vi. c Facilky 11)"'orapplicable)
rtam Ri Aw &iannm 944
Physical Address,01q.;tlld Zip
21.RE.NIIRKS
Count.\ Parcel Identification No.I PINN;
5b.Latitude ana iongitude in degrees/minutes/seconds or decimal degrees:
tifwell field.one I:, lorL!i,suffiteicnt) 72.Certification:
6.Islam)the or [3Ttmporan, /9 naitire ofCcnified Well Contractor Date
Hv 1'
;;j,form,i livreh.1, wrii/v fficst the Are/16i will twerv,ontsirric;ed tit accordance
7,Is this it repo;-roan existing well: E]Yes or a
If this il,trepair, n iwiit cnivirucli(n)infiwinalmn widexplati,the;iallfreofthe Ol/!V al 1/1;,record lrte,been prorided to ilie well owner.
repairuinki- 23.Site diagram or additional well details:
8.For Geoprobe,,DPT 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;, -1 is needed. Indicate TOTAL NUMBER of wells constructior.details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1)5
00 24a, For All Wells: Submit this form mithin 30 days of completion of well
For multiple well.,1­,,,:,,1,-('1h,11 d"iter'-w 1cwwnph-3t—(C21)0,and 1(d (11Y)
construction to the fiollowing:
10.Static water!i­c!below top of casing: it, (ft.) Division of Water Resop's-c'es.Information Processing Unit,
lfwaler/4"vi IS lih,."­;­.Q.lilt' 1617 Mail Set-vice Center.Ritleigh,NC 27699-1617
11.Borehole diameter: Id G (in.) Nb. For iniection Wells: In addition to sending the form to the address in 24a
above.aiso submit one copy oflhis:•lblnn within 30 days of completion of well
12.Well constrl,t6(,f,method: IN 0VMr\-)_ conslruci:.,n to the following:
(i.e.auger.rotar\..:,;,ie.aitect push.etc i
Division of Hater Resources,lundergirclund Injection Control Program,
FOR WATER yk PH.) WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(-pm) Method of test:Ot'01 11. niVAW 24c. For NV ater Sumo I I
v& Injection Wells: In addition to sending the form to
the addre�isiesI above. also SUbinit;one cop� of this form withir, 30 days of
I , YS
l3b.Disinfectio,) ,%­oe:0h1or;ne, 4above.Amount: 19J completion of well construction to the county health deriannitent of the county
where constructed.
Fenn G%k*-1 North Carolina Departinent of Environmental(?u3b:%-i)iN Nion ot"N'ttier Re,-(-zirc e, l Revised 2-22-2016