GW1--04731_Well Construction - GW1_20230724

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
• 1.Well Contractor Information: /►
•
���C - /.',^K/Jp J� / s L"t �! �tC 14.WATER 7.ONES i'.. ':
G I / Btrl FROM TO DESCRIPTION
��'ell ContractorNae /// ft. ft. / ,55 / d 2. 1�3-
/-J / Q . ft. ft. /65s' , J ! /
NC Well ConttactorCertification Number 'S:OUTER CASING.(for multi-cased wells)OR LINER(if up licable):::_'.. :='.. .
/ 1FROM TO DIAMETER TIHCKNESS MATERIAL
I-e i' LL//L S La-e t/ GV G�')r f`((i.r) .1 eC I- I ft q,R ft /_7g in. O 0 5 / V C
Company,Name •'16.INNER CASING Olt11 B NG(geothermal closed-loop)'- -:-:: .
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: /00`p 3 & q 11 - ft. It. in.
List all applicable well construction permits(i.e.County[State,Variance,etc.) _ ft in.
3.Well Use(check well use):
17.SCREEN.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
ft ft. in.
OGeothermal(Heating/Cooling Supply) i? esidential Water Supply(single)
' . ❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT •
FROM • TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation Non-Water Supply Well: D ft. A b ft. en-ken`tk pc9`-<.c-e d
It, ft.
❑Monitoring ❑Recovery
Injection Well: It. ft.
•
❑Agmfer Recharge 0 Groundwater Remediation 19 SAND/GRAVEL PACK(if applicable):
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fL It.
❑Aquifer Test ❑Stormwater Drainage
It ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach'additional sheets ifnecessary)
❑Geothermal(Closed Loop) OTracer FROM I TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks) ( 7 R, o/0 ft R e d G/Gt.i
4.Date Well(s)Completed: 7 5' '` a3 a 0 ft. to 0 ft. 19 6 fi.e`dee
Well Location: /o 0 ft q�fr. P�/�` / P_ ir / j�L� /„c T
( ,', 9 2 ft aCP , d Lu e t� ,Jx car �►Z�
��- -I►011 [I ft. ft. �a
Facility/Ownery/ Name y ,/ Facility'Di/(if applicable) ft, ft �,�,� q �/ �
•
g / 17 LI / r ha ft It. ' S a ° -
P►lysical Address,City,and Zip 3
•21,REMARI{S JUL �: t1 :(O2�".:..
/Y)e Cif'Ge» .6CCr Y
County Parcel Identification No.(PIN) l jfif OD rtLK�"��i Ur
t,�_�!r�:G�t�G
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5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: � )
(if well field,one(lat/long is sufficient)
) t/ .
350 1 ! / / / N go . t 9 057 W ��2� � -```�' '7 S �-'�3
� go of ified Well Contractor Date
6.Is(are)the well(s): L1Permanent or ❑Temporary By signing this form, I hereby certify,that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or l copy of this record has been provided to the well owner.
If this is a repair,fill out known well constriction 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: 1 / 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: a 0 (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 0'and 2@100') construction to the following:
10.Static water level below top of casing: 3 (ft.) Division of Water Quality',Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: &/" (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
. .'2.Well construction method: 0/Let_T y , construction to the following:
e.auger,rotary,cable,direct push,etc.) / '
Division of Water Quality,Underground Injection Control Program,
'13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) /, Method of test: in i
/r 24c.For Water Supply&Geothermal 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: 3 ; fs completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality • Revised Ian.2013