GW1-2022-02978_Well Construction - GW1_20220302

-WELL CONSTRUCTION RECORD QW-1) For Internal Use Only:
II.Xviell Contractor Informadon:
14.WATER ZONIIS
all CoOttatxorName FROM TO DESCRIPTION
xc w"u 1&OUTIM CAMM r muld-cases wells OR LII�Et uceb a
by-al�"2� �l �b�(�� �i{1� MOM To DUNMI11a Tfffcx - NSIUA.
Company Name
16.121NERCASINGORTOBING ihermalclomd400
2.Well Construction Permit : FROM I TO DUMEM THICKNESS MATERIAL
Ust all applicable well consiniction permits(i e.Ul Counts;State,Variance,etc.) ft. 8. in.
3.Well Use(check well use): ft. ft. In.
Water Supply Well: 17.SCREEN
FROM TODiAMaTaB SI.OrSIM TMCKNM MATERIAL
Agricultural E)Mumicipal/Public G FL It, tn.
Geothermal(Heating/Cooting Supply) bIt deal Water Supply(single)
ft, ft. in.
Industrial/Commercial DResidendal Water Supply(shared) 1&GROUT
lrriaafion FROM TO MATERIAL EAMACENOWNIRMOD&AMOUNT
Non-Water Supply Well: f- Y0
Monitoring eco_Very M ft.
ri—wecdon ell:
ft. ft.
Aquifer Recharge 13Groundwater Remediation
19.SAND/GRAVEL PACE fitanplicalAel -
Aquifer Storage and Recovery Salinity Battler FROM TO MATERIAL EMPLACBNIHNT METxOD
Aquifer Test OStomlwater Drainage ft. %
Experimental Technology DSubsidcnoe Control
Geothermal(Closed Loop) DTracer 30. RIIMG LUG.attach additional sheets N
-.Geothermal(Heatin Cooling Return) 13Other( lain under#21 Remarks) FROM I TO DESCRIPnON rotor bmda 60wiods
ft, ft.
4.Date Well(s)Completed: ' —OeLQ Well II1fl ft. &
Sa.Wtil Location:
tt fL
/ k__Jf dRl it. ft. !b� G.... ..
aeility/�a Gr 7�"�� Facility W#(d applicable) ft. ft. MAR 0 2 7
k 31 6 506,L well R2 116 fL ft.
physical Address.City and Zip ft. ft.
oyl' V_'I Y/'I,1 -A�„ 41(4431 21.RBMARS3
County perl identification No.(PN e.</, like"
6b.Latitude and longitude In degrees/Hdnntes/seconds or decimal degrees:
(if 11 field,one mat/long is sufficient), 22 rtl6cadon:
2
,� lq
6.b(are)the wells) .,Permanent or Temporary Signature of Certified ell Contractor Dare
� By signing this form.I hereby certify that the PxHis)was(were)constructed in accordance
7.Is this a repair to an existing well: �=es or 13146 No with 1SANCAC 02C A100 or 1SANCAC 02C MW Well Construction Standards and that a
If this is a repair,fill out ktown well construction inforotarionand explain the nature of the ropy of this record has been provided to the wen owner.
repair under#21 remarks section or on the back of fidsfonn. 23.Site diagram or addition W well detills:
8.For Geoprobe/DPr or Closed-Loop Geothermal Wells having the same You may use the back of this page tD provide additional well site detaf7s or well
construction,only i GW-i is needed. Indicate TOTAL NUMBER of wells construction details..You may also aftch additional pages if necessary.
drilled: 1 9UBbrtTr T INS"ULTrONC
9.Total well depth below land surface: / ) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(emmple-3@200'mid 2@1005 construction to the following.
10.Stafic water level below top of casings (ft.) Division of Water Resources Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (lit.) 24b.F-hr-IftlectlaixWeDst 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: ko�� construction to the fallowing
(ie.augey Iotaty,cable,coact post,etc•) �
Division of Water R_onroea,Unawsg m a h{I ac Contror 1►rogrnw,
FOR WATER SUPPLY WELLS ONLY: 1636 Mari SeMce center,Raleigh,NC 27699.1636
13a.Yield(gpm) Method of test: 24c.For Water Suouly&Inle don In addition to sending the form to
the address(es) above, also submit one copy of this farm within 30 days of
13b.Disinfection type: Ahnonnt: G Completion of well WIRStWOR to the county health department of the county
where tmnstmeted.
Form GW-1 North Carolina Department ofEnvitonmentai Quality-Division of Water Rmur cm Revised 2 22 2016