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HomeMy WebLinkAboutGW1-2022-02960_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