GW1--03822_Well Construction - GW1_20230609

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Weil Contractor Intor tion'. _ -
R. •NES
m FROM TO DESCRIPTION
Well Contractor Name ft' ft.
In ft. H. -
NC Well Contractor CoRiHaetion N bar 15 It•G ' .G,tor•in ceased wells OIt INER its cable
FROM TO DIAMETER 1HICisTfESa MATERIAL
Company Name 16.' :C ' ITVG'R, 0; 'edt ermal'•o mad-loo
�a r jl`L ' . 1 L FROM To nLLMETER 7 tlicKNEas MATERIAL
2.Well Construction Permit#: /ti tt• tG l"
Llst all applicable well construction permits(Le-UIC,County,State,Variance,eta) fR ft. In.
3.Well Use(check well use): 1•..S' EN
l Well: FROM TO DIAMETER SLOT SIZE yHICIQtES3 MATERIAL
rN
Supply Ft. g,
ltural �MunicipallPilblic
R sidendal Water Supply(single) K, ft.
ermal(Hcatinglcooling Supply) @. PP Y g )
pp•��Residential Water Supply(shared) 1s.• ft•UT
riaUCommercial E� FROM TO EMPLACEMENT METHOD&AMOUNT
tion o ft. ) ft. R.e JY/ a A
ater5upply Well:
ery ft.
Recov to
Monitoring ft.
injection Well; ft.Aquifer Recharge Groundwater Remediatlon 19.SAPfD/G YEI MATE
:FA Y. t`.a 11 a le• Eh1PLACEMENT METHOD
�'Salinity Barrier FROM TO RIAL
Aquifer Storage and Recovery \ ft. to
Aquifer Test _,t.1 .3Stormwater Drainage
<'
ft, ft.
Experimental Technology +,,%. Subsidence Control
I7acer 20,'I)RILL et:i
IN OG. ttaeh 'il. Httnal8hefnaoessa
Geothermal(Closed Loop) � PROM TO
DESCRIPTION color hardaesr�oWrock elxe etc
Geothermal H mtin COOIin Return 2 Other(explain under#21 Remarks O f4 / ft. I G
s ./ fL y�
4.Date Well(s)Completed; Well EN 5 R i$ tt. ft.
5a.Well Location: ry, ft. ,
Facility/Owner Nama FROMIDfI(if epplicabla) t I ft. ft. I� �) p
Physical dress, .ity,and Zip ARKS rr ft rc
2I.RE
I.t yl 2
County Parcel Identification No.(P1N) ,
5b.Latitude and longitude In degrees/minutes/second or decimal degrees: 22.Certification:
(iCwau Held,one ladlong is sufficient) .. � � r � � , Y
3 S r � N
signature of Certi9ed Wall Contractor
Date
6.Is(are)the weli(S) rmauent or Temporary• ay signing this farm,l hereby cert(/y that the wells)was(were)constructed to accordance
Yea or {�No with CAC 07C.O100 or lSA NCAC 02C-.0200.Well Construction Standards and that a
7.Is this a repair to an existing well: ® copy 1SA 15A N record has been provided to the well owner.
Ifthis Is a repair,Jill out known well construction Irl/ormatlon nd explain the nature ojthe
-repair under#21 remarks section or on thg back of this ford. 23.Site diagram or ais
dditional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Lbop,Geothcrmal Welts having the same construction details. You may also attach additional pages if necessary.
construction,only I GW-1 is needed,-.Indicate TOTAL NUMBER of wellsatunTrAl 3NG I RUCTIONS
drilled:
de
below laud surface: (ft•) 249.Ear All We s: Submit this form within 30 days of completion
9.Total well d of well
For muhtple wells list all depths(rdfferenf(example-3Q300"and 2®100� construction to the following:
(ft.) Division of Water Resources,information Processing Unit,
lo.Static water level below top of casing: 1617 Mail Service Center,Raleigh,NC 27699-1617
if water level is above casing,use"+" ,
11.Borehole diameter: Z 24b.F r In on V ll :' In addition to sending the form to the address in 24a
above, submit also sumit one copy',of this form within 30 days of completion of well
12.Well construction method:
1^ construction to the followtrig:
(ix,auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground Injection Control Program,
. 1636 Mail Ser'v ice Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY: H to
Method of test: N 24c,For Water Sum a•Injection Wells: of addition
form swithin 30e days of
13a.Yield(gpm) the address(es) above, also'submit one copy
G.Ct- p YL. Amount: iC• completion of well construction to the county health department of the county
13b,Disinfection type: where constructed.
Revised 2.22-2016
North Carolina Departrnoat ofBoviromnmtal Quality-Divisloo of Water Rebources
Form OW-1