GW1--05030_Well Construction - GW1_20230804

WELL CONSTRUCTION ION RECORD(GW-1) For Internal Use Only: •
1.Well Contractor Information:
•
QGG�II �I
U FLiI l< 7.'.. I,1 QVti Ielj 4-7t `v— `' 14.WATER ZONES-- 1
Well Con star Name I ti,ti,e,i...-j Ir,.- ) -i®'...j FROM TO -DESCRIPTION
35'-k-1 AUG 0 6 2023 300 R. 3oS4- 11� ��
J�qb.�ri. LIT)0 ft. I/'1 tb 61./ '
NC\h"ellComractorCertification Number 15_OUTER CASING(for multi-cased wells)OR LINER ifa Iicable)
{,-It p.. t 1 I s�" ..i�:=.n s:w'..'. 111ti. t-uotil TO DiAm (. p
1,c-+ 1 I'�-{ S Li 1� r t 1II, j VI,la.-A.0/504; EI�R THICKNESS MATERIALI'c-- ----
Company Name I (� l f4 R. l/y in •0�` �i
'MANNER CASING OR TUBING(geothermal closed-loop)" -'- -"'
2.Well Construction.Permit is 3a1 LECI3 FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(Le.U/C.County,State.Variance.etc.) ft. It. in.
3_Well Use(check well use): ft- It. in.
Water Supply Well I7_SCREEN NIA
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL—
DAttricultural ❑NIunicipal/Public ft_ it. in.
EGcothcrmal(FleatingiCoolina Supply) 'iRcsidcntial Water Supply(single) R, rt. in.
QIndttsttial/Commercial °Residential Water Supply(shared) I8_GRo1i r 1
❑litigation ❑Wells>100,000 GPD FROM TO 3LITERIAL I EMPLACEMENT:METHOD E AhIOL3T
Non-Water Supply Well: 0 ft_ ft. ��,t e,�- —
❑il-IonitorinR QRccovcft- ( �� r-e
injection Well: 4' 7J a ft. �1j �, — �� ,��
R_ ft_ to et t f�
❑Aquifer Recharge OGroundwatcr Remediation 1
19_SAND/GRAVEL PACK(if applicable) A A
❑Aquifer Storage and Recovery ❑SalinityBatrier FROM TO MATERIAL EIIPL&CE\IENT3IETHOD
❑Aquifer Test DStormwaterDrainage ft >C 1
°Experimental Technology °Subsidence Control ft_ ft_
°Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary) • (
❑Geothermal(Heating./Cooliug Return) • °Other(explain under 421 Remarks) FROM in DESCRIPTION(color,hardness,so;Fmck One.amain sae,ewe_) 1
4:Date'Well(s)Compieted:© I ia . d‘ + u- )
el!Mg- J ft: ft .. 4
tfi ' sq14_,_ --pPL2..
Sa wen Location: 1 O ft 9.0
S� ft. �
/
Erb 1�/�y S�✓`Q)v, rt.. u. Cv1
racthtsr Nance :.tt. tt.
•
Facility IDS"(if ...
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i'ltysicat Addi>ss.City,and Zip n ft
IarY tee, 0421 1 0( o((3 -21_REMARRS,- . . ..
County .,, . .. i Parent identification No.(PIN) .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one fat/long is sufficient) 2' ertiflcali
'36, R o (oST t. 'Z 'o 2,9 691 w� / l/��'Z
6_Is(are)the weli(s): Permanent or Cl empuran '1• enattire 'Cetti a ell Contras De,�
by signing this jinni. hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: °Yes or )1 o ISA NC IC 02C.0100 or I5,1 iVCAC 02C.0200 ilill Construction Standards and that a copy
If this is a repair.Jill out known well construction information and explain the nature of the ol7his record has been provided to the well owner.
repair wider#21 remarks section or on the hack of?his form
23.Site diagram or additional well details:.. ... .. .. ........ .
You may use the back of this page to provide additional well construction info
3.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the suns
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary_•
an(tut / 24.SUBMITTAL INSTRUCTIONS '•_ _ _
9.Total well depth below land surface: 1,DS (ft.)
For multiple wells list depths if dillerent(example-30);00'ond 3 n't 100� - Submit this GW 1 within 30-days-af well completion.per the followings -
10_Static water level below top of cuing: 3Q 24a. For All Wells: Original form to Division of Water Resources (DWR),
ifuntcrlerclisabatecasing;tens" .- . _ - _ ... .- -
O Information Processing Unit 1617 DISC,Raleigh,NC 27699-161.7i - -
i 1.Borehole diargeter [C) (in.) 24b. For°Injection Wells:Copy to.DWR,Underground-injection Control(IUC)
Program.163E MSC,Raleigh,NC 27699-1636 '
0-(-R R( ►4R1- -. - _. u - ice
12.Well Construction method:__. � 24c.For Water Supply and Open-Loop Geothermal Return ti\'ells:..Copy-to the
(i.e.auger,i-cdary,cable,direct push,etc.) county environmental health department f the county where installed
FOR WATER SUPPLY:WELLS ONLY: 24d.For..Water Wells producing over 100,000•GPD:Copy to DWR_CCPCUA
Permit Program,1611 MSC,Raleigh;NC 27699-1611
13a.Yield(gpm) I i►2ethod of test l
13b.Disinfection 4.pe:4 r,i, r'i(Q_i Amount: /oZ 12 Z
Font OW-I f
North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-20lS