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Home My WebLink AboutGW1-2023-02949_Well Construction - GW1_20230425 i 1i1,..7.7.7_. _ 'WELL CONSTRYJCTION RECORD(GW-1) For Internal Use Only: I.Well Contractor Information: ---Rs`-t}a fC ( V\)t(.,1 K Ai i 3(-1 J 14.WATER ZONES 1 ! - Well Contraclo Name FROM T• •-O DESCRIPTIOLN f`:'C� IQ ft. r:� �('• f1. Lid!*1 e (Srlt cf • '( J.rs ft. ;7 7 n. /1,;(ed t5 4?A..0( . . NC Well Cont clot Cenific lion Number IS.OUTER CASING(for multi-cased wells)OR�LINER(if ap licable) ` i .�� r i ` FROM TOO- DIAMETER THICKNESS MATERIAL� - � • 1 I �- / ft. /57 ft. la. 3 Mo r:V L Company Name I^ ��I(,� 16.I INNER CASING OR'TUBING:(geathermal closed•loop) • 2.Well Construction Permit#: 'v`JJ O( v O H. FROM TO DIAMETER THICKNESS . MATERIAL List all applicable well construction permits(i e.UIC;Counry',State.Variance.eta.) H. IL In. •3.Well Use(check well use): ft.• fL la 17.SCREEN Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL Agricultural •Mu icipal/Public (s7 ft. 17 J ft. t In, a(,/(, Lk) PV( . • Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in. Industrial/Commercial DResidcntial Water Supply(shared) 18.GROUT. Irrigation FROM TO MATERIAL EMP1ACESIENTh1E1IIOD&ANOINT Non-Water Supply Well: b ft. r. ft. m 6rc_rt 1 '114 J -- - hlonitor(ng-- - - Recovery-- — ft- • ft.- - -- - - - - -- -- Injection Well: ft. ft. Aquifer Recharge Groundwater Remediation . 19.SAND/GRAVEL PACK(if applicable) Aquifer Storage and Recovery IDSalinity Barrier FROM TO MATERIAL EMP EMETT METHOD Aquifer Test 0Stormwater Drainage 160 ft. /77 ft. 0*a , °per Experimental Technology Subsidence Control ft. ft. T Geothermal(Closed Loop) • `]Tracer I0.DRILLING LOG(attach additional sheets'If necessary) ' FROM TO DESCRIPTION(color,hardness.solProek type.grain size,etc.) Geothermal(Heating/Cooling Return)r [Other(explain under#21 Remarks) d ft. /' ft. G l 4.Date Well(s)Completed: J . 3 Well JD# • IQ - ft. ., :.ft. .. ,- / ,,� . , 5a.Well Location `, • - gqJ , l ,I :ft' - 4(141 15'J.R /•77 fL c41I .' i- - . ir"1"e (t r) - - . Facility/owner N me _ Facili IDH(if applicable) ft. ft. Cg1,,:Ci �' �e. / /. ' -- -- - • ft. ; f4 At Il G 7 2a7 �=(1 ref . /,/,ri r '��l��lll , •- Pbysy,l.�adress.Giry,and Zip 2 t fi- t '�(". 1/j II.REMARKS n lar2---,yiu a]l!t`.' County - Parcel Identification No.(PIN) 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field,one lat/long is sufficient) 22.Cc c on: N IV /z....... • 6.Is(are)the well(s) crmanent or ]Temporary ignature it red Well Contractor Date -By sign ;is form,I hereby certify that the walls)was(were)constructed in accordance 7.Is this a repair to an existing well: IJYes or No whit ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a- Ifthis 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. repair under 021 remarks section or on the back of this form 23.Site diagram or additional well details: S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary. drilled: �'-7 SUBMITTAL INSTRUCTIONS • 9.Total well depth below land surface: / 7 (ft.) 24a. For All Wells Submit this form within 30 days of completion of well For multiple wells list all depths ifd8erent(example-3 00'and 2(@100') constmction to the following: 10.Static water level below top of casing: C 9 5 (ft.) Division of Water Resources,Information Processing Unit, ifuvter levelIs'above casing.use"+' - 1617 Mall Service;Center,Raleigh,NC 27699-1617-- . ' ' 11.Borehole diameter: (in. gide>, 24b.For Infection Wells: In addition to sending the form to the address in 24a �I flL• above,also submit one copy of this Foinl within 30 days of completion of well 12.Well construction method: IIII construction to the following: ' i (i.e..suger,rotary,cable,.diirect push,etc.) Division of Water Resources,Underground Injection Control Program, -. FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service,Center,Raleigh,NC 27699-1636 - 13a.Yield(gpm) 'Method of test: 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 13b.Disinfection type: Amount: completion of well construction to the county health department of the county where constructed. • Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources' Revised 2-22-2016 , I