GW1-2023-02465_Well Construction - GW1_20230404

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.well Contractor Information: L}�
•f d[i 7 J - - t4.'R1'AT R. NES
FROM TO DESCRIPTION
Well Contractor Name ft. I ft.
t-I 5 Li 5-A ft.
NC Well conaeetorCortifloation Number f5, ' 7rgR•C (for•m iet:it Priells 01i INER if.a cable
FROM TO IA
DIAMETER TffiCIOYPS9 MATER
C,m o s I� I) a vt.d Pv►tit r� ft, .7 o ft. 6.125 VC
Company Name / 6.' CASILVO Q 'T. ed1'erm^al,d QSsd-too
�t G FROM TO DiAhrETE 1 TffiCKNE83 MATERIAL
2.well Construction Permit#: iy ft, tL
List all applicable well construction permits Ae-E C County,Stale,Variance,etc.)
it. it. •l°•
3.Well Use(check well use):
Water Supply Well: FROM I To DIAMETER 9LOTSIZE THICKNESS M-----I
Agricultural C)MunicipaMbiic ft. D• 1D
Geothermal(HeatinglCoollng Supply) MR@sidontial Water Supply(single) H, ft. �.
Industrial/Commerciel E)Residondal Water Supply(shared) 1s,• It 11T
FROM TO TERIAL EMPLACEMENT 11>ETHOD&AMOUNT
Irrigation © h• K
Non-Water Supply Well: ' a
Monitoring DRecovery n• ft.
injection Welt: tt. fL
Aquifer Recharge ®Groundwater Remediation• 19.SAND/G •'YEL FA. 1G 'Buttlicatile.
Aquifer Storage and Recovery, '\ oSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test �,,' ;;�1••,
[3Stonnwater Drainage n f t
Ex erimental Technology s.�`'"�'1` Subsidence Control tt, ft.
Geothermal(Closed Loop) Tracer 20.ISRiLLIN LOG. ttach d d4n .sheet:ir-neeessa
FROM TO DESCRIPTION color,hardness soWroek alu ale
Geothermal (Heating/Cooling Return .Other(explain uader#21 Remarks 7 g,
4.Date Well(s)Completed: Well ID# PL L IJ k• r �^ t �'-T , "z
5a,Well Location:
ft.10 i�vtetS. ft• p R ►I
ft. ft.
Faollily/Ovaer Name Facility 1DM(if applicable)
' ft. ft. ;
Physical Address,City,and Zip
2T. ARKS
�yrk2 _
County Parcel identification No.(PIN)- =
5b.Latitude and longitude In degrees/minute-9/second!,or decimal degrees:'
(ifweU Held,one laf/long Is sufficiept) 22.Certification:
3.5,17q '3 6 N , ',V 535 3-5
f CartiHed
Signature o 'We U Cantra I Data
6.[s(aie)the weU(s)OPermanent. or Temporary.
BY signing this font;1 hereby certify that the well(,)Ivan(were)constructed In accordance
7.is this a repair to an existing well: ®Yes. or WO with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ijrhia Is a repair,Jill out known well construction lvtformatlon and ezplaln the nature ojrhe copy ojlhts record has been provided to the suer!owner.
•rEpair under#21 remarks section or on the back ojthls form• 23.Site diagram or additional well;details:
8.For Geoprobe/DPT or Closed-Loop;Geothermal Wells having the same You may use the back this page t provide additional well site details or well
dlcate.TOTAL NUNIBER of wells
construction details. Youu may also attach additional pages if necessary.
construction,only 1 GW-1 is ntdeded,-'ln
drilled: r.__ RMiTTA1.iNSTRiJCT�ONS
9.Total well depth below land surface: %) (ft-) 24a; For All Wells-. Submit this form within 30 days of completion of well
par multiple welts list all depths(jdVerept(ezarl+ple-'3@200'and 2Q100) construction to the fallowing:
10.Static water level below top of easipg;, - (ft.) Division of Water Resources,Information Processing Unit,
Ijwater level is above caving use"+" 1617 Mall Service Center,Raleigh,NC 27 69 9-1 63 7
11.Borehole dlstnele*r: (in-) 24b.For Injection Wells: 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: b r,i, construction to the following-
(i.e.auger,rotery,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
n it 24c.For 'later SuDDIv&injection Walla: In addition to sending the form to
Method of test;
13a.Yield(gpm) the address(es) above, also submit one copy of this form within 30 days Of
136,Disinfection type: C� 0 Amount: � Lv completion of well constriction to the county health department of the county
where donsttucted.
Form 4W-1 North Carolina Department of Environmental Quality Division of Water Resources Revised 2-22-2016