GW1-2021-02698_Well Construction - GW1_20210811

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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�C t.�� s � 14.WATER ZONES
Well CotruactorName � To DESCRIP7TON
Oy c.��C a55�- �' PAC. rce�5�� o � (Q o � ��d� /coxa•ris�. set Et,c.
(3(� rt:0� 9a C0612Sa S"6 /&46LL
NC Weft CbffmwwrCcaA1h N wrNa#nbv, %'U'- e� 15.OlTfER CASiNG Obr mafN-cased wells OR LINLIR tin Hcable
�� FROM TO DIAMETER THLC[a1as MATERIAL
-�k�tZit A•44 k*—AkJ . � f Q M O' fL �p rt. � t° Sc h � AT
Company Natty Q y VC
16.INNER CMING OR TU81NG thermal er
2.Well Construction Permit#:3 5 1 19 J FROM I DIAMMW I THICKNESS I MATERIAL
List all applicable weII construction permits Cis UIC,Cow*,State Variance,etc.) f4 ft Id
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3.Well Use(check well use): & lD'
Water Supply Well: 17.SCREEN
FROM TO I DIAMETER SLOT SI7E I IMCKNESS I MATERIAL
Agricultural 0manicipai/Public ,3i7 ` 4o r` 14 In , C,l0 ;E �Ho (,C
Geothermal(Heating(Cooling Supply)residential Water Supply(single) go tti q O ft. ln. . 1 G Cx 1�A �.
Industtial/ComniMial ❑Residential water Supply(shared) 11.GROUTS i
ler7 'on FROM TO MATERIAL EMPLACEMFNTMETHOD6�AMOUNT
Non water supply Well: O f
irb
Monitoring [311ccovery ft. R.
Injection Wen: IL tL
Aquifer r,whargo: []Groundwater Remodiation 19.SANWGRAVEL PACK cable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACKMENT METHOD
Aquifer rest [3Stormwatcr Drainage eZ 5 [00 C.Gx�/� t�Ge9 P le�
Experimental Technology ❑Subsidence Control it tl
Geothermal(Closed Loop) Tracer 20.DRILLING LOG atpch additional sbeets ff
Geothermal eatin lin Return Other(explainunder#21 Remarks FROM TO DESCRIMTON color,hardn aaNroek in etc
t+u.(>G
4.Date Well(s)Ctrmpleted:��y-a WeIl D)tf 3G APOfL
S 6Cfe.Ll-
5a.Well Location: Coo fa go fL C LA /SAUL S Am
-S01k1J 815;ScaAA1ZTT e9Q ' G'G ' C04ME 544 /SclEt.t_
Facility/Owner Name FacH4 D)#(ifapplicable) iG IL too IL F11141:. YA-Alb
102 .*PEf_ICA-A! CTnl.C..2 2- ft. fL
Physical Address,City,and Zip & f
C (^U)Ar(�- t 21.RFMARKC
Cmmty Parcel Identification No.(PIN) Ab"M ' 41-So .So U b CA&
5b.Latitude and longitude in degrea/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 2L Certification:
6.Is(are)the well(s) ermanent or Temporary Signature of Certified Well Cofactor Date
By signing this form,I hereby certify that the:velits)was(were)constructed in accordance
7.Is this it repair to an eldsting well: DYes or 3�o with 15A NCAC 02C.0100 or 13A NCAC 01C.0200 Well Construction Standards and that a
If this is a repair,fill our brown well conetruetion information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarknTectton or on the back of this form. 23.Site diagram or additional well details:
&For Geoprobe/DPT or Closed-Loop Geothermal Wells having the game You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is neede& Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: ` SJ1BM=rAL fNSMCTWNS
/9.Total well depth below land surface: 0 d Fr 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple we1b list all depdaT ifdVerent(exa"0 30200I and 2Qa 100 construction to the following:
10.Static water level below top off casing: (M) Division of Water Resources,Information Processing Unit,
if wrier level is above easing,rate"+- 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: -7 7e _(in.) 24b.For Infection Wells: In addition to sending the-fDrm to the address in 24a
above,also submit one copy of this farm within 30 days of completion of well
12 Wen eonstrnedon method: (/ Rc�Ti4 P.y construction to the following:
(i.e.anger,rotary,cable,direct p°sh,etc.)
D!s#stov of WaaerRewourveff,U—Jerg—ard Iefechoe Control Program,
FOR WATER SUPPLY WELLS ONLY. 1636 Mail Service Center,Raleigh,NC 276994636
13s.Yield(gpm) � Method of test: x(12 bEV. 24e.For Water Samdv At Lifectlon Wells: In addition to sending the form to
[[�� the address(es) above, also submit one copy of this fort within 30 days of
136.Disiecitob�pe~41y(!+c t teo@+T� AtnouDt: �j ©�. completwhere ion of cotlStluctii.to the county health department of the county
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Form OW-1 North Carolina Depattmew of Envimumental Quality-Division of Water Resources Revised 2-22-2016