GW1-2021-02674_Well Construction - GW1_20210811

i
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well.Contractor Information:
''QIJf l .Q�j►'�� 14.:. ATER20NE9'.
Well Contractor Name FROM TO DESCRIPTION
ft. ff. I
2 i
rz"1, 6
NC WcI1 Co clef Ccrtificetion 77,ro S'7/�" v1/� .: RCi1gI1V •for.tmulN=,tesCil:tve 1r U "h;�IiVD$.� 1e IlcatiDle ...•.. :: '
S FROM fL ATFRIAL
ft.TMO D`�JrR in. �Y!\/J nI V c-
CompanyName CA5 (1qR G 'eoth'rma I6ed.loo
2.Well Construction Permit#• /a— FttoM I ro DIAMETER THICKNIMS I MATERIAL
List all applicable well consMmllorr perndts(1.e.UIC,Cornrrr,Slate,Variance,e11.5 ft. ft. In.
3.Well Use(check well use): ft. ft. In.
Water Supply Well: 1N C N: •'. :.;.:,... _ :. ..> :.
FROM TO DIAMETER SLOTSI7.E THICKNESS MATERIAL
Agricultural QMunicipaVPublic
Geothermal(Heating/Cooling Supply) &gldentlal Water Supply(single) ft. ft. In.
Industrial/CommercialResidential Water Supply(shared) 182 QRgUT
Irri ation FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: f. ff• en-fe4 e- OxL he S
Monitoring E3Recovory ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
•10.'NAND/CRAVE AC 'if's' llcablo •
Aquifer Storage and Recovery 13Salinity Baffler FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage n• ft.
Experimental Technology OSubsidenco Control ft. IL
Geothermal(Closed Loop) Tracer 20::DRI a a;att c .edilfHonHks'eefs ecesaa
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardoeaa toll/rock type,grein slze ere.
ft. 64 ft.
4.Date Well(s)Completed: ��/'�1 Well ID# n' ft.
Sa.Won: 0 r� � r � ��� ft. ft. _
::WnEt.—ti M I LI>✓r u ff. ft.
Facility/Ownor l4ame 1 Facility ID11(if applicable) R• ft.
ft. ft.
Physical Address,,City,and Zip
QJ ft. ft. �CQSStn�
Or1 JK l� .Y1.
County Parcel Identilication No.(PIN) Q
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, /et
one lettlo/ngg Is sufficient) / 22.Cer If1 It n:
6.Is(are)the well(s)OP- m ranent or Temporary Signature of Certifkd Well Contractor Date
By signing this fo,•n,I hereby cerlify that Ike well(s)Has(were)constructed In accordance
7.Is this a repair to an existing well: r.lYes or MNo wilds ISA NCAC 02C.0100 a•15A NCAC 02C.0200 Well Construction Standat*and that a
if dots is a repair.Jill aril known well conslr ucilon blformallon And Nplain the natmv of the copy of this recovd has been prodded to the well owner.
repair under 1121 remarks section or on the back of thisfornt.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: _(D•) 24a. For All Wells: Submit this form within 30 days of completion of well
For nm/nple wells 11st all depths ifdiffetent(example-3 20 'and 2@100) construction to the following:'
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
If water level Is above casing.stye"•P" 1617 Mall Service Center,Raleigh,NC 27699.1617
11.Borehole diameter: w (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: b &y construction to the following:
(ke,auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail SoMce Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) Method of test: AJ r 24c.For Water Sunnly&Infection Wells: In addition to sending the form to
t the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: S completion of well construction to the county health department of the county
d where constructed.
• i
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016