GW1-2023-02094_Well Construction - GW1_20230307

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
1.Well on Into motion: t
Get (+
(4.vl'ATER.7ONES
FROM TO • DESCRIPTION
Well Contractor Name ft. ft. i
LI5 q 5 A • . fr. ft. ; V
NC/ Well Contractor Certification Number ///�` I 15.OTTl RCASING.(fbr•inu)tl+cased wells)OR LINER'(lf EPt lllllcable)
L 1 t y ibnaS I and f V WL - FROM TO DIAMETER THICKNESS I MATERIAL
I •
ft.
78 �.6,/25 SPR2i I ( VC
Company N ��) I6:INNER:CetiSIl1G OR'TING(f edtherm�l'elosed-loop)
2.Well Construction Permit#: "'— FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(ie.VIC,County,State,Variance,etc.)
ft. ft. In.
ft, ft. In•
3.Well Use(check well use): .
17.SCREEN'. .
Water Supply Well: FROM TO DIAMETER ' SLOT SIZE THICKNESS MATERIAL
Agricultural ,0MunicipalPitblic ft. ft In.
Geothermal(Heating/Cooling Supply) wltgsidential Water Supply(single) ft, ft. in.
Industrial/Commercial E3Residential Water Supply(shared) 18.•GgOUT. V
Irrigation FROMy TOr�/ ��`` �TERRIIA&,L EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: V f. .2_O ft .? .ri1i'k )4 L
Monitoring Recovery ft. ft.
rs-
Injection Well: rt. ft.
Aquifer Recharge ®Groundwater Remediattan• .19.SAND/GRAVEL PACK.(If appllcahle).
Aquifer Storage and Recovery . DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
'\ •'
Aquifer Test .`�•, [�Stormweter Drainage ft. ft.
Experimental Technology ,'`,.! OSubsidenceControl ft. ft.
Geothermal(Closed Loop) Tracer 20.'DRILLING LOG.(attac'h a ddiHbnal.sheets:ifnetesaary)
Other(explain under#21 Remarks) FROM • TO DESCRIPTION(color,hardness,soil/rock woe,grain size,etc.)
Geothermal(Heating/Coolingq Return) ( P ft, 7 fr. C `1� •
I
4.Date Well(s)Completed:OZ'2 O/e3 Well ID# 7e1 f t• 405 ft. V v a vt i'.i''t,
_ ft. ft.
5a.Well Location: '
f/- ft. ft.
INN I-vl—/CJ KTCYT - ft. ft. I. Y ,51
Facility/Owner Name Facility ID#(if applicable)
&V'V, ' fil4cc� ft. n MAR f'.� / [L►Z3
Physical Addr ,City,end Zip .
� �^� ZI.REMAIN
CQun�, 4I' G.l Parcel Identification No.(PIN) s'' IfiS�' _- . ...` _7
5b.Latitude and longitude in degrees/minutes/secont]e or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
. 52 I N — ill.'7 $,33 w . � ^ �, , 62. �1-,.3
, ' Signature of Certified Well Contractor Date
6.is(are)the wells) Permanent or OTeinporary ill///
By signing this form,1 hereby cert(fy that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: fYes orPlo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction Information and explain the nature of the copy of this record has been provided to the well owner.
••rdpair under 021 remarks section or on the back of this form. 23.Site diagram or additional well details:
�; You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop;Geothermal Wells having the same construction,only 1 GW-1 is needed.'Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
.. drilled: SUBMITI'AL INSTRUCTIONS
9.Total well depth below land surface: 9 0'.6 (ft-) 24a: For All Wells:- Submit this form within 30 days of completion of well
For multiple wells list all depths((different(ezarpple-3®200"and 2®100') construction to the following:
10.Static water level below top of casing.;: q 0 (ft•) Division of Water Resources,Information Processing Unit,
If water level is above casing use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole dram!ter: 6 (IL) 24b.For Infection Wells: In addition to sending the form to the address in 24a
. A above,also submit one copy of'tliis form within 30 days of completion of well
12.Well construction method: A` `v,r, construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) II Method of test: �f ►r" 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
I� IF�
13b.Disinfection type: Vi^l✓t6 Amount: 9 CiU ').S completion of well construction tb the county health department of the county
1 where constructed.
t
. Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016