GW1--06387_Well Construction - GW1_20231009

•......-..,,. vvi w$. It.J.1V101'i .'JLSJJ For Internal Use ONLY:
'
This form can be used for single or multiple wells
1.Well Contractor Information: / i
�� Y I e 1 �7c e1 i,e/'• /8'>a"2P� `� l4.WATER ZONES- . I •
/ P FR0�7 TO DESCRIPTION
Well Contractor Na a ft ft
ti/0 O ft. ft. I ,
NC Well Contmctor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(Wan livable) '
FROM TO DIAMETER TRIMNESS MATERIAL.
Ct in6C 1 Wye!( r',Z( .7iz'- 1--/ ft• 76 ft. 6:/sin. ,O S /'LC
Company Name 16.INNER CASING OR.TUBING(geothermal closed-loop) •
[ FROM TO DIAMETER THICKNESS MATERIAL
�
2.Well Construction Permit#: • ( '116 2 0/ - / • It it i in.
List all applicable well construction permits(i.e.CounO: e,Variance,etc.)
ft. ft. 1 in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public R' 1°'
❑Geothermal(Heating/Cooling Supply) >311esidential Water Supply(single) ft. ft. 1n.
❑Industrial/Commercial ❑Residential Water Supply(shared) ; 18.GROUT . •
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Obligation -
•
Non-Water Supply Well: 0 ft" A 0 ft PPfll t0 ri'Ye f O ca r e Cl
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft it. 1
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)• '
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
ft. ft. I
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft. ft. I
❑Geothermal(Closed Loop) ❑Trader 20.DRILLING LOG(attacb'additional sheets if necessary). - .
FROM TO DESCRIPTION(color,hardness.soWrock type.grain size,ete.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) a ,ft 8 0 ft i Wecf c/ram
4.Date Well(s)Completed: q e2 / 013 g(/� ft- 9 6 ft fn `��i, �h*- i'; ,'`4,,
5.Well Location:
Facility/Owner Name J Facility IDff(if applicable) _
CLJ /�4• ft. ft
Physical Address,City,end ZipILI /+ n
.- i / � 21.REMARKS 0 C T G 9 �V 2S ,
g
County ParcelldentificationNo.(PII�, In "^ :^' : . :. `�� I_'C5
DWC.1
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
Orwell field,one lat/long is sufficient)
35. 49330 / N 790 '77384/ w rqe �-a/'1.z3
�, '*of ed Well ConnectorDate
6.Is(are)the well(s): fills�rmanent or ❑Temporary By signing this form,I hereby certify;that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Eitigo copy of this record has been provided to the well owner.
If thts is a repai,;fill out known well construction 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: / construction details. You may also attach additional pages if necessary.
For multiple infection or non-water supply wells ONLY with the sane construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: N.[-0 Q (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths Ifdiierent(example-3Q200'and 2QI00) construction to the following: 1
10.Static water level below top of casing: 60 (ft) Division of Water Quality,Information Processing Unit,
Ifuater level is above casing,use/"+" 1617 Mail Service Center,Raleigh,NC 27699-1617 C�11.Borehole diameter: /g (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
12.Well construction method: /l D a 7construction to the following:
(i.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) 0 Method of test:
/9/'Ir. 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: l f r� Amount:_„ 1/7-3i. S completion of well construction i the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013