GW1--06631_Well Construction - GW1_20231017

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
A �
1 'h-`‘A.kl 15 AitiWATEzzoNE9 , !:,i:c. f•a' > .?:.r :1 a=. i.' l'' .,
FROM TO DESCRIPTION
Well Contractor Name A90 ft. _QDOft. / I G per.
0 38 - A Soo ft. 114.P ft i(i 6 PM
NC Well Contractor Ce,•,•,•���f��•••'.666���'''�ion Numb r A 15:OUTER'.CkBING{for'iniilti-eiised wclls)'OR*LiNER,(!f'ep beoble)°5:
�LI.0 J' -1 J P f• , td)ILi 11,1 FROM TO DIAMETER THICKNESS MATERIAL
Company Name
!]�� W 1YQ\ / ft. 60 ft. to i/4/ la SDR.Z1 PV�.
Part V '.,16.INNER CASING_OR�TUBING{geotlfernml.closed-loop)' s`Lci: .........::i`:i: i
D DD/D FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft ft la
List all applicable well construction permits(i.e.County,State,Variance,etc.) f
ft. fr. / • in.
3.Well Use(check well use):
'.'Y9'SCREEN it:OF r':.`. .C',F:',i: . Mi _7S'z .......i, `:.,L .•i1:_ „b:.1
Water Supply Welk MOM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑A ❑Muni ' al/Public
(cultural ft ft, +
❑Geothermal(Heating/Cooling Supply) f sidential Water Supply(single) ft. ft. •
❑Industrial/Commercial ❑Residential Water Supply(shared) •
18;"GROUT.r ..'t,
FROM TO MATERIAL E CEMENT METHOD&AMOUNT
Obrigation 0 ft. 2 Sf ft. /.�_,�t i e- tyre`
Non-Water Supply Well: �r+�es
❑Monitoring , .. , . , ❑Recovery . . _ ft fr. DID e/(0
Injection Well: ft. , ft.
❑Aquifer Recharge ❑Groundwater Remediation i19 SAND/GRAVE(PACK(ifapN(cable) 1. ! ,,4:
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
❑Ex erimental Technolo fr. ft. •
P gY ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer '20 DRILLINGS OCWittacli arldrdorial'sbeets':if a'ecessary) ;.;, s a .•;r
PROM• TO DESCRIPTION(color,hardness,soli/reek type,grain she,me.)
OGeothermal(Heating/Cooling Return) �J_❑Other(explain under#21 Remarks) Q ft. ZD ft- tz50/�
•
4.Date Well(s)Completed: / 2 z"-a.Z 6 Z 3 a 0 fr. (a 0 ft. 4 ob p 1�-0
ft. &0 ft. coS64,
S.
�tWell,Location: 6 p ft'
f 4. ft
f-tiou l Free(Y -� ft —r ft cSDGi,p
Facility/Owner Name Facility ID#(if applicable)
7A0$ `Tinto-l-isy-oR.. CoNeord . G.[G ft ft � �.!��., aY a..
Physical Address,City,and ZipI.
.21:RF.MARIzs.cgi i, dS ,y. -
CIRI3ARe�.S Co 00010 CCT:�I t 2o23
County Parcel Identification No.(PIN)
5b,Latitude and Longitude in degrees/minutes/seconds or decimal degrees: a C' ,�s° sZ
Orwell field,one hat/long issucient) 22.Certification: la
3Soffii9/S3 •
N SOb c 7? .
jlte.
e o Certi ed Well Contractor i Date
6.Is(are)the well(s): 113, ermanent or OTemporary
y signing this form,I hereby certi 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 o copy of this record has been provided to theiwell owner.
If this is a repair,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:
•
E' 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 injection or non-water supply wells ONLY with the same I construction,you can
submit one form. i1�,����,`�� 24.Submittal Instructions:
�1
9.Total well depth below land surface: "4146 (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 t©200'and 2©100' construction to the following: •
10.Static water level below top of casing:
t (ft.) Division of Water Quality;Information Processing Unit, •
If water level is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617 .
tit .
11.Borehole diameter: (o (in.) 24b.For Infection Wells: In addition to sending tire form to the address in 24a
�oC� above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction 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: h 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) l 1 I l 2- . Method of test: ill IS. 24c,Fdor Water Srtpply&Geothermal Wells: In addition to sending the form to
�hle�s e the address(es):above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 7e1,7 completion of well construction to 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