GW1--06907_Well Construction - GW1_20231030

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
1.Well Contractor Information: •
'
�1 c 1(C.� —t�1'''y�t•--[-e) 14.WATER ZONES
Well C/ontractorName FROM TO DESCRIPTION
NC Well Contractor Certification Number 'IS:OUTER (for multi=cased wens)OR LINER(TA)'licable): ' ' " • "
(Lark(
' ' •u J 19 c r 'J `-Y_1 G K FROM TO DIAMETER THICKNESS MATERIAL
Company Name �1 U ft. 6! ft. 1 ; in. s h , ro-c.
.16:INNER CASING OR TUBING(geothermal dosed-loop). _ . .
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL -
List all applicable well construction permits(i.e.UIC.County,State,Variance,etc.) ft, ft. I in.
3.WellUse(check well use): ft. ft. i in. -
Water Supply Well: 17 SCREEN -. - . . ' --.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural EjMunicipal/Public 0 ft• ft. in.
Geothermal(Heating/Cooling Supply) (�,,esidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT '
Irrigation FROM TO MATERIAL EMPLACEMENT HOD&AMOUNT
Non-Water Supply Well: 0 ft. ft. �o' J . p�,, ass Cam/ �0rJI'5
Monitoring ecovery ft. '73 ft. ' rCi
Injection Well:
ft. ft.
I Aquifer Recharge L_.Groundwater Remediation '
19.SAND/GRAVEL PACK(if applicable)-_ _.
Aquifer Storage and Recovery 01Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 1:31Stormwater Drainage ft. ft.
Experimental Technology DISubsidence Control ft. ft. ! l .;�
Geothermal(Closed Loop) DTracer -20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
/`� ft. ft.
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4.Date Well(s)Completed: `1/S./e `Well JD#Yla i l q i ft. ft.
5a.Well Location: ft. ft. •.ti.,.'L • �'' / �' I
Fr OA c < Glnn(�.p ft. ft. OCT 3 0 2023
Facility/Owner Name
�r�,, r 1 Facility ID#(if ap/plilicable (( ft. ft.
`-'14 Mbar if ��licit.1J PS "W�tll .1/""-- ft. ft. Ii1,v:' '.. ^,a,hj•_�,e,,,a,;pey Lira
Ph sisal Address,City,and Zip ft. ft.
-21.REMARKS;
etSs-r� ( 1 ; I: _.r- ter- l-Q.®-�,
County Parcel Identification No.(PIN) , -5
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r
(if well field,one lat/long is sufficient) 22.Certification:
6.Is(are)the wells) ermanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ,. .or ONo with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
You may use the back of this page to provide additional well site details or well
construction,only 1 G)V-1 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: 3 (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@200'and 2 tf 100') construction to the following:
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10.Static water level below top of casing: p' <5 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699.1617
11.Borehole diameter: & .) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above,also submit one 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 Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ' 6 Method of test 24c.For Water Supply&Injection Wells: In addition to sending the form to
f the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 11—A rr Amount /ciN--5' completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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