GW1-2023-02356_Well Construction - GW1_20230331

This form can be used for single or multiple wells I
1.Well Contractor Information: -
G�j� `` Gy� / _ / 14:WATER ZONES `."
/JEC U�'!� rJe?!��/�/�E�'�/ P, /�eC/7 PY FROM TO DESCRIPTION
Well ContmctorNa/me ft. ft. 65 //0 `/ 2 el -). 30
r2 O3 lD _ ft. ft. l .2-6 U
NC Well Contractor Certification Number •:.15zOUTERCASING(for iuutti-cased-wells)OR LINER(if ap licablc)
FROM TO DIAMETER THICKNESS MATERIAL
. C. �u//i s we(/ IJr,'<<% tic ! ft. q 3 rt. b% , raS' PL/c
Company Name 16.INNERCASING ORTUBING;( eothermal closed-loop) ;• ` ... .
^ ^o ry /�., FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: O( o/ "/ ft. rt. in.
List all applicable well construction permits(i.e.County,State.Variance,i etc.) ft ft, in
3.Well Use(check well use): 17.SCREEN . . . . .. . .. r.,- '
Water Supply Well:• FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipallPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) �idential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) ..18.GROUT:
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation d ft. rI Q ft. ��en�On P o u r e d •
• Non-Water Supply Well: ft. o� ft.
❑Monitoring ❑Recovery
Injection Well: rt. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVELPACK(if applicable)- , . .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
fL ft.
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20:DRILLING-LOG(attach additional sheets if necessary)': '- .' '. - '.
OGeothermal(Closed Loop) DTracer FROM TO DESCRIPTION(color,hardness,soil/rocktype,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Othse�r(explain under#2IRemarks) 6ft. av ft• ed C
4.Date Well(s)Completed: 3 7-p�.r2��]f-o2 3 410 ft. by3 ft GWee4 ,
5.Well Location: 'I 3' 300. -•' Z,,Q 6
. ft. ft. - .
,cLl •
ft. ft '[. s i' s
Facility/Owner Name Facility ID#(if applicable) ft. ft.
-'5.3 Q l .5 A er i d 4.ri Rd ft. ft. �� 3 1 7(17�
-
Physical Address,City,and Zip 1;.;.:G,,:,5; -",:•.._.,
21.REMARKS - .:,j �t:nt
. �Ctbo) rr�, � ,�»7�,
. County Parcel Identification No.(PIN) t
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) ,
350 i iH5 33 N Sae '7 3/av w ,c ► 'V•e-/A 3 -.2-01-23
� � Signature of Certified Well Contractor Date
6.Is(are)the well(s): lBPermanent or ❑Temporary
I By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Elf copy of this record has been provided to the we!!owner.
If this is a repair,fill out known well construction information and explain the nature of the
. repair under#21 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.Number of wells constructed: / construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. . 24.Submittal Instructions:
9.Total well depth below land surface: 3 f/ e (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(g200'and 2@100) construction to the following:
10.Static water level below top of casing: `. 5 (ft.) Division of Water Quality,Information Processing Unit,
r If water level is above casing,use/+'• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: V /r7 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
/� above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: /1 Ott r S/ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
i,13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
/� t 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) CJ Method of test: the address(es) above, also submit one copy of this form within 30 days of
113b.Disinfection type: /4771 Amount: 'Ot n f S t completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013