WI0100483_Geothermal Well Construction Record (GW1)_20170706

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Robert Larry Wells t !
Well Contractor Name RECEIVED1NCDF-0(S J p�'1
2603-A
NC Well Contractor Certification Number J U L 13 2017
AWD Services Inc.
Company Name II
WI 0100460eratlons Section
2. Well Construction Permit #:
List all applicable well construction permila (.e. Caunry, Steve, Variance. etc.)
3. Well Use (check well use):
For Internal Use.QNLY: .
+r. ft,Rid e
ft. ft.
.15.:OUTI±R:CASING— foe piultitased $tells gD LMIL rf
FRoM TO WAMEM TIIICKiV8.S4 MATFdiIAt
ft. t�.
:1fr Im!iF�iiF.[rASIlYGo ; MING&�tii��.r as °1da
FROM ' TO 1 DUMLTI'x.tt ML" SS MATERIAL
0 $ 290 ft' 1.2 IN'
n 11 HnPF
ft. ft. in
__rr_l _. ____
ZEl !cultural ❑MunicipaMblic
'thermal(Heating/CoolingSupply) ❑ Residential Water Supply (single)
❑IndustriailCommercial OResidential Water Supply (shared)
❑liTig,ation
ft. I
ft. I
in.
FROM
To
MATRRI
N7c Uc- Supply W c I I
❑Monitoring ❑Recovery
R.
ft
Injection Wel :
El Aquifer Recharge ❑Groundwater Remediation
ElAquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test CStormwater Drainage
QExperimental Technology ❑Subsidence Control
1ieothermal (Closed Loop) ❑Tracer
R
ft.
19.:5 N DIGRA.IzLPA
if ii '" lid
FROM
To
MATH
ft
ft.
rt:
ft.
2&:D LL
ClflC> altaelia3'di
FROM
I TU
DESCRU
4. hate Well(s) Completed: 7/5/17 welt 1I1#
rt.
ft.,
5a. Well Location:
ft,
Bronwen & Jerry Rispone
ft.
ft.
FacilitylOwner Name Facility rdii (ifapplicablc)
%
332 Walnut Valley P_kwy Arden,_NC 28704
ft.
fw
Physical Address. City, and Zip
21. REMARK$::...:
_ -- Rimmmhe qF7465751- __
County Parcel rdentificalion No. (PIN)
5b. Latitude and Longitude in degreeslmtnuteslseconds or decimal degrees,
n. CerHtI tion:
(if well field, orm lat/long is sufficient) nt Elev. 2309'
35 27 54 82 36'21
11shLviIl Rer)inr')l offic;
N W
6. Is the 341 ❑Temporary
igoature Cettifie ji ell Contmotor Date
(are) well(s): monent or
BY signing This form, I hereby certify 1hot the kwll(s) was (were) constructed in accarrkrnce
with 154 NCAC 02C.0100 or IM NCAC 03C.0200 Well Construction Standards and that a
7. Is this a repair to an existing well: ❑Yes, or MI
copy of this record has been provided to the wel! owner.
If this is a repair, fill out known well construction hformallon and explain the nature of the
repair under 921 remarks section or on the back of thisfarm.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8. Number of wells constructed:
construction details. You may also attach additional pages if necessary.
For multiple infection or non -water supply wells ONLY Willi the some consducdwt, you can
submit orie form.
SUBARTCAL INSTUCTIONS
3 290'
9. Total well depth below land surface: (ft.)
24m. For All Well : Submit this form within 30 days of completion of Weil
For multiple walls list all depths fdfftrent (example- 3[200' and 2@1001
construction to the following:
10. Static water level below top of casing: NIA (m)
Division of Water Quality, Information Processing Unit,
Ifwaler level is above casing, use "+"
1617 Mail Service Center, Raleigh, NC 27699-1617
11. Borehole diameter: 8'25 (in.)
24b. For Iniection Wells: In addition to sending the form to the address in 24a
rotary
above, also submit a copy of this form within 30 days of completion of well
12. Well construction method:
construction to the following.
(i.e. auger, rotary, cable, direct push, etc.)
Division of Water Quality, Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
1636 Mail Service Center, Raleigh, NC 27699-1636
13a, Yield (gpm} N/A 11lethod of test: Gal t"'n nta i ner
74c. For Water SnEgly & Iniection_Wells: In addition to sending the farm to
the address(es) above, also submit.one copy of this form within 30 days of
13b, Disinfection type: Tablets Amount: 2
completion of well conMotion to the county health department of the county
where constructed.
Form G'W-1 North Carolina Department ofEuvironntent Enid Nature[ Resources = Division of Water Quality Revised lan. 2013