GW1-2023-01544_Well Construction - GW1_20230218

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: T
7Q d 6 CCN AA tie ` 14.WATER ZONES
/y FROM TO DESCRIPTION •
Walt ontractor Name /.4 it. 8 L R (-ruk n. � Nn„] 5 AIt
3/fi-A `i -1 �7 J
NC WeilContractor
CCcrtifcation/Number (� IS.OUTER CASING(f (for multi-cased wells)OR LINER(If ap Ileable)
G(AA }+f Q1 y W e 11 ���() • ' y' y 1 DIAMETER T O a�tw reRtAl.
It ft. in. PU C
Company Name Jo[[�� !q 16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit# l`: WS.c,la- 1 0 v !� FROM TO DL4M1iTER THICKNESS MATERIAL
11. in.
List all applicable well construction permits(Le UIG County,State,Variance etc) _-
rt. It in.
3.Well Use(check well use): - -
17.SCREEN
Water Supply Well: FROM TO DIAMETER7 I SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 4yft. �lk ft. in. /6 iiO l vc-
❑Geothermal(Heating/Cooling Supply) 1pittrigntial Water Supply(single) ft. ft. in.
_ l
Dlndustrial/Cotnmercial ❑Residential Water Supply(shared) IS.GROUT
❑irrigation .❑Wells>100,000 GPD FROM TO MATERLtL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: / R' AO ft Pettey PC L t
❑Monitoring DRecovery it. rt. -
Injection Well: ft. ft.
'DAquifer Recharge OGroundwater Rernediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL x'..MPLACEMENTMkTI1OD
. ClAquifer Test ❑Stormwater Drainage EP Q R' ell it. C;'% 00 V r
❑Experimental.Technology ❑Subsidence Control it ft.
DGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets If necessary)
under#21 Remarks) FROM TO DESCRIPTION(color,loudness,tail/rock/rock type,grata dze,etc.)
❑Geothertr;al(xeatinpfCooling Return) t]other(explain// Li 7 /f� It y L., ft- t.S�'lq S hl,<<$
4.Date Well(s)Completed: /-1(3-23 Well ID# ,[it�'1- ti 4 rt. ey f ft. �1 GS pr m S d -
fL
5a.Well Location:
' R. ft
U INSilt%i k*A '2' Bur\AeCS f . ft. -
. Facility/Owner Naine Facility lDir(if applicable)
/G3S E-r36(n Co(ony P!, IJAsh�vlyfov, n•C. ft.R. IL -
Physical Address,City,and Zip it
6-7 ep f3C •
21.REMARKS
•
county Parcel Identification No.(PIN)
' 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
3sufficient)(ifwcll field,one lat/long is 22.Ce ication: ..„1.4
� Signature of Certified Well Contractor Date
6.Is(are)the well(s): 12"Fermanent or ❑Temporary
By signing this form,Ihereby certify that thewelf(s)was(r•ere)constructed in accordance with
7.Is this a reply to an existing well: ❑Yes or iif[o ISA NC.AC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,. 11 out lamb t well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21{'emarla section or on the bock of this farm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same
coiisiniciion,Drily 1 GW_-I is needed. Indicate TOTALNMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: LJ24.SUBMITTAL INSTRUCTIONS -
9.T sal well depth below land surface: t (fr') Submit this GW-1 within 30 days of well completion per the following:
For rrl ultiple wells list all depths ifdi fferent(example-3 a0200'and 2Q100')
2 aa. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 41. (it) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-I617
If water level is above easing.use"+"
11.Borehole diameter: 6-�
1 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
(1n•) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: m V C> 4gT1 1 24c.For Water Supply and Cpca-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary)cable,direct push,etc.) county environmental health department of the county where installed
FOR WATTERSUPPLY WELLS ONLY: , 24d.For Water Wells producing over 100,000 GPI: Copy to DWR,CCPCUA
} Method of test: / ;f' Permit Program.1611 MSC,Raleigh,NC 27699-1611
13a Yield(gpm) 1
'
13b.Disinfection type: k►11�1t\�Q_, Amount: 02
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018