GW1-2022-02964_Well Construction - GW1_20220302

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Onl.:
1.nZContracctor Information:
C);-S4' V\4z: 14.AATir".R:ZONES
Well ContractorNante FROM TO I DE90" Tlah
--';� fz
NC Well Contractor Cenification Number
`\ If U.OLri'ER CASING Ifor multisased.wells I OR LINM fifaniffienNel
FRo31 TO DMIETER •rinctaTM atATERint.
Company Name
16.INNER CASING OR TUDING' thermal elaied400
2.well Construction Permit#: �/i//( � d FROM m 1 DIAMETER l..TMCkhM I slaTF[t).at.
lr>Y all applicable well aim intainn pem6ty(i.e.UR'.Cinm(i:Stare,t ariatce.eic.) it Z R- it- in. Q Gil O ,rc-,
3.Well Use(check well use): 2 2 R. 2 3 tt. in •]�,�C�t{O; J C'
F-Agricultuntl
ly Wall: 1Z SCREEN
FROM TO DIAMETER SLOTSIZE. TBICK.NESS %IATERiAL
`Mtmici ublic .- a `,
L l p)q n. 22 ft. to s0-1 J�-Ct.�O -plc..
l(Heating/Cooling Supply) OResidential Water Supply(single)
R.
Commercial Residential Vl�te�Su tc(abated)' pP iL GRO FR01h TO " 11tAlERiAi ERtPI ACE1ifRT UE7TiOD d Ai1)OL�T
Non-Water Suppy,Well: R. ft.
Monitoring ecovery ft. fL
lnjecdonWell., f?. ft.
Aquifer Recharge OGroundnater Remediadon
19.SANDIGRAI`EL:PACK IT avolicablej,
Aquifer Storage and Recover [Salinity Sarver FRon) TO, MATERIAL I > trtat +)ia+.r METHOD
uOD
:,Aquifer Test DStonnwater Drainage 15 0' 2 3 fL t+.tt
Experimental Technology Subsidence Control fi R.
Geothermal(Closed Loop) Tracer 20.DRiLL1NG LOG attech eddhiaaal sleets ifnecersa
Geothermal(Heatin Cooling Return) Other(' lain under 1121 Remarks) FRot,) To DEsdurnoR i:o>or.Mess.solumek mmsots size.etc.)
% tr.
4.Date Well(s)Completed: 2 g010L Weii IDf1{'Smy tA ft. f.
Sa.Wei Location: ft. ft.
ft
FacilitytOwnerNante Facility tDt (ifeppiicabie) R• ft.
Pj=,sical (City.and Sv / it. % AR U
N& O 1� 21.RENiARIKS
County Parcel Identification No.(PiN) 6,
n v; S7Ni fi};`F't ('^'C
Sb.Latitude and longitude In degreedminutedsecond.or decimal degrees:
(if%vela field.one harlong is sufficient) 22. iieation-
��_
6.is(are)the welt(s)OPermanent or [ Ttmporary Signature. atified►yell Contractor Date
qy signing ihls form,l helYLt'L'L'nfr drat dw itYII(s�it•as(irl'tei avxmn(aed.iti aCCtlr[btniC'e
7.Is this a repair to an existing well: Wes or �'o tdih 15A AT('.I(:02('.DI00 rtr l Sit RC,101('.0200[I:�1 CmnvniCth a StmularrG mtri dwi o
if diia is a repair.Jill om knmm irell rmistrudimi igfonn-ab"zn d i*am the rtmnre afifte cnpy t fthis record liar heat prmided to*-a irr11 miner.
repair under=21 irmada sealon or an the bark afrhisfonn.
23.Site diagram or addidonat w elUdetails:
8.For GeoprobeIDPT or Closed-Loop Geothermal Wells having the same 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: SUBMUrTAL INSTRUCTIONS
9.Total well depth below!t)od surface, V� ( ) 24a. For An Wens: Submit this forTn within 30 days of completion of well
F''ormnlriple irells list all depihe iftfiffmm(example-3 r,l�i 200*aid 2 1601 construction to tit foilo%Ang:
10.Static water level below top of easing: � �^ 0L) Dh3sion of Water Resources,Information Processing Unit.
(lusnerlerrl is above casing.use 1617 hail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection NVelts: 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
i.e tech rdaTy.able, inctfiod: . �� construction to the foilowing
(i.e.auger,rtilery,cable,direct push.etc-)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUIPPLY MTELLS ONLY- 1636 Mail Service Center,Raleigh,NC 2709-1636
13s.Yield(gpm) Method of test: 24c.For Water Suoniv& Iniection Went:: in=addition to sending the form to
the address(es) above, also submit'one copy of this form within 30 days of
13b.Disinfection type: Amount•. completion of well construction Wthe county beelth department of the coulity
where constructed.
Form GW-i Nonh Carolina Devanment of Emironmental Oudifiv-Mision of Water Remurces