GW1-2022-02960_Well Construction - GW1_20220302

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Onh-:
1.R'�1 Contractor infor ation:
\//\®lT v` ���p�J50*J 14.IVATER2ONES
Well ConlractorName FROM TO I DFSCRIVrIOr
ft.
NClNell ficN7 \�
H.OUTER CASING formuld•cesed*vUs ORL11`'ER cable
/ -%t -M D1AA1rMR' T1rt KN'F_SS MATERIAL
ft. ft in.
Company NamN I&ININTR CASI IG OR TUBING: thermal dakd4i o
il-
2.Well Construction Permit#: FROM To I DIAME78R'' T luji�ms AtATERtAL
List all applicable well crmmrrohni permits(i.e.I4C.C(mntr;.dare,l ariwwv.etc.) `:►� ft. 1 b a. ^ +n V
3.Well Use(check well use):
lYaterSupplyWell: Fxov� TO aLOtEAR staram I TxiC70\05 I MATFttiae
Agricultural OMunieipal(Public 0 ft; tt, to
Geothermal(Heatine/CootingSopply) 0hesidential Water Supply(single)
Oft- 0O
Industrial/Commercial DResidential Water Supply(shared) aB.GROvr _
lrrt nDn FROM TO AtATFAML 01PLACLVENTMET110D&AMOVINT
Non-Water Supply Well: O ti. .Z a ft.
Monitoring Recovery ft. (t
injecdonWell: tr: tL
Aquifer Recharge oGrounduater Remediation
11SAND/GRAVEL PACK ifab]e►'
Aquifer Storage and Recovery Salinity Barrier FROM.. TO wA AL: EAtPLAC>a�MTNIEI'tIOD
tt. tt-
AquiferTest [ SiomatatcrDrainage ytJ v ,SA %A
Experimental Technology []!Subsidence Control
Geothermal(Closed Loop) [Tracer 20:DRILLING I.OG attuctiaddfdaml's muifnecma
Geothermal(Heatin Cooling Retum) 00ther lain under#21 Remarks) :FRO31 To DESCRWnON t hardmLsownKt r shereto
ft. •ft.
4.Date Wells)Completed: z !fell ID# fa ft-
Sa.Well Location: 3b ft' too fL
Facility/Owner Name Facility M9 0f applicable) &
_
33 V.mw lacry.-, 2 7 (a2 MAR 0 2 2022
Ah�cal Addpss,Chy and Zip ft. ft.
21.REbfAMMO.WTO
County Parcel tdenti(icationido.(PIN) Rr(LE`•` 1 1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if mll field::oae latt[ong it sufficient) 2 ertiileation:
3 2`� �� N "? dot" 85 3.(0 '2, , 2 2g 2 Z
6.Is(are)the well(s)Qffermanent or tilery Signature ert(fied Well CA=tractor Dace
lli•stpting this form,l hmhr rear fr that the irelils/}+ac(Irriv)crmunrcred in acrordcnrce
7,is this a repair to an existing n-ell: [3Yes or QKo rr lh 15A Ai AC O(-,01iI0 ur 1514 XCA(;02(*_0200 Me*Cnnvtucthm 9tnulan&vid i1mi a
If this is a mpair.fill out kimrvr i e/l wniimciml intunnad lurid LTdaru the notate a fthe ow of this irxanl has been p rnrded tot irell ruiner.
ttpai,nnrkr=21 mmarfa srcvlon'tw mi dw bark afthir fo'nn.
23.Site diagram oradditionatwell deigns:
8.For Geopr•obe/DPT or Closed-Loop Geothermal-Wells having the same You may use the back of tills page to 0mvide additiortai well site details or tell
construction.only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnemsar3•.
drilled: SUBMITTAL INISTRUCTIOIVS
9.Total well depth below land'surface: ' (o (D•) 24a. For Ail Weils: Submit this form within 30 days of completion of well
13)r multiple udis lLn all depths tfdi emm(example-5@200``•lard 2@1001 construction to ft following:
10.Statie water level below top of casing: J�� (ft.) DhWton of Water Resources,information Processing unit.
(tamer level Le ahorr caking use--" , 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (� 011.) 24b•For Injection ti`e0s: In addition to sending the farm to the address in 24a
12.Well coastruedon method: _ A 9-�
above,also submit one copy of this form%Athin 30 days of completion of well
(Cc.auger,notary,cable,direct push,etc.) construction to the folloWng:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY AITLLS ONLY:, 1636 Mail Service Center.Raleigh.NC 17699-1636
13a.Yield(gpm) 2 Method of test. ^4 24c.For Water Suonh<&iniection 3Ws: in addition to sending the form to
}-� the address(es) above, also submif one copy of this form within 30 days of
13L Disinfection type: ^t\ Amount. ,14 V, completion of well construction to,the county health department of the cottifty
where constructed.
Form GW-1 North Carolina Deoanment of En%imnmental OaSlfty-nicidan of Water Rean� n..�-.i�_»an►c