GW1--05889_Well Construction - GW1_20230918

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
L.Well Contras r Information: I
OW G /
i 14.WATER PONES
FROG TO DESCRIPTIO.
Weil Contractor Name ft. !fie ft.
,,ctjA.S.....1fr
ft. �v ft.
NC Weil Contractt2i C'cttiificaatiJoi Nuurhhers, d— 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
ON
//1 �' ,(J J`/ /--1 P� 'Y Y)i FR I ?/� DLpk\�tt:'rER THICKNE'S,SnMATERIULV //////�/�w�/(�'/ f! YYY lrr 11Y//[[[/// ft. f/I ft, • - in. 5/t.�/1� —0 Ole Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
V 2.Welt Construction Permit#: Lir , /t (, ' - Lei FROM TO MAMETE:R THICKNESS ( MATERIAL
List all applicable well construction permits 0,e.UiC,County,State,Variance.etc 1 ft. ft. in.
3.Well Use(check well use): fr. ft. in.
'Waiter Supply Well: I7.SCREEN
FROM TO DIAMETER SLOT SI'�.t TmcIc tEssS�, MATERIAL.
1 Agricultural nlclpu!•'Put�lic /}n R. /�®ft. in. �/f 5041
/11� t;�.{) 1 //1/
i Geothermal(!1eating/Cooling Supply) Residential Water Supply(single) ft. ` ft. in. �/ ,/(�� 8 V V(�
Industrial/Commercial DResidentiai Water Supply(shared) IS.GROUT
711iri'ation FROM T MVATERLiL EMPLACE-NI EAT METHOD£AMOUNT
Non-Water Supply Well: , ft. Mill OQn° • P ev Pew°
•Monitoring 0RccoA•cry, ft. ��+••e�� �1I! _ . . .__
Injection Well: ft.
Aquifer Recharge DGrottndwaler Remediation
19.SAND/GRAVEL PACK(if applicable)
`Aquifer Storage and Recovery DSalinity Barrier t I5O\I 'TO M TF hAL EMPLACEMENT METHOD
:Aquifer Test DStornnvater Drainage _ tO ft. D o tt• v ip 0
IS Experimental Technology D Subsidence Control ft. ft. J
•Geothermal(Closed Loop) DTracer 20,DRILLING LOG(attach additional sheets if necessary) V
'Geothermal(Heating/Cooling Return) Other(explain under 421 Remarks) PROM TO DESCRIPTION tr ter trurtlnxss,soittruck type,gran size,etc.!
62 ft. ft. TV l
4.Date Well(s)Completed: _ Vell iD# b IL (IZI1 ft. G�G�
fr. ft. ,._.,,.-J r. ..,.,,
5a.Well Lo ation: tvifri
te 1 i ,; .,,1 •=r i k I �G r ft. i/,�1 ft. �j N.1.,.•.Asa .t V 1...
1J "u/ Vl� r/
'eF cilit /Owner frame facil'ty ID#(i.applicable) ft, ft. C+F p 1 8 2023
�i�)�/U v W k ft. ft. J`r
F'thys''al Address.City.and Zip ft. ft. IR {t^ ?.'"C }; tf
put/
a EAN :f„.
A,,,,, 1 e rori+ -21,12ENIARK .
County Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: °VP' ,
(ifsvell field,one int/tong is sufficient) 22.Certificati•on:
ataLt.
6.Ls(are)the well(s) Permanent or Temporary
Signatun of Certified eli ContractorDaleBy signing this form.I herehp certi(v that the well(s)teas(were)t•oncirutled in accordance
7.is this a repair to an existing well: Elites or No with 1S.4 A'CAC 02C_0100 of IS.'t PICA('02C.0200 Well Construction Standards and that a
If this is a mink,fill out known well construction inlnrmation tied explain the nature of the copy of this record has beet:provided to the well owner.
repair under#21 remarks section or on the back q/7his form.
23.Site diagram or additional well details:
8.For Geoprobc/DPT or Closed-Loop Geothermal Wells having the same You may use the hack of this page to provide additional well site details or Ave!!
construction,only I GW-I is needed. Indicate TOTAL.NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I G V (ft.) 24a. For All Wells: Submit this form within 30 days of-completion of well
For multiple wells list all depths ifdifierent(example-3(112(111))''twd 2tty100') construction to the following:
10.Static water level below top of casing: ((,� (ft.) Division of Water Resources,information Processing Unit,
I(unter level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: E (in.) 24b.For Injection Wells:,hi addition to sending the form to the address in 24a
)/,t��, / above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: l>14/ r itartfo construction to the following:
(i.e.auger.rmary,cable,direct 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(gpnr) 15- Method of test: 24c. For Water Supply&Injection Wells: In addition to sending the form to
/t,� gam• the address(es) above, also submit one copy of this font within 30 days of
13b.Disinfection type: *O ( Amount: tl �` • completion of well construction to the county health department of the county
where constructed.
Forth OW-1 North Carolina Department of Environmental Quality-Division of Water Re:minces Revised 2-22-2016