GW1--07187_Well Construction - GW1_20231101

CORD GW-1 For Internal Use Only:
WELL CONSTRUCTION RE '
1.We Contractor Information: titiZO • .;,-'=.; s:�: .' - -- `'L:' .J • '.
;FROAT NES;tii', 'ia
DESCRIPTION
FROM TO
Well tra for Name / •
® „. �rf
G fonmult cuedli ell's)OR1J E11
,a,•lrcab'le.ma's:-rsxt.t %%''-
:eFROM7TERGTO D��
NC Well Contractor CertificationNumber FROM
TT}O�
an Well&Pump,INC ru>- eotuer; iaosieo, z ;;
EIIIIIIIII
Company
a16:INNER•G° I C.O1Z• THICKNESS •,.
2. e Name. w.1 A•��_ '`w't�. FROM TO
L•Well Construction c Permitn .e.UIC,County,State,Variance,et )
construction permits(i
List all applicable well P ® 1_Y ',::_ 4,tiz' : =
n:� . F.i ems:�! :
SC RFE1sLi�' ,._.;;.i: . 3s.. . _ .. 3:: THICIOVES
3.Well Use(check well use): 11111111111.1011.111111111111111111
tFR SLOT SIZE S —
FROM T® D®_
Water Supply Well: DMunicipallPubli
Agricultural Water Supply(single) in. `r.` ;,;.
Geothermal(Heating/Cooling Supply) " ;1ResidentialVT uPP �) • ._.• .....,,: .:.�`r.•>.�7.�,•T;�:;;.ti::_. :.... �'
* 1.111111111111111111111
DResidential water Supply(shared) r gg GIZO�T'= J1• `EMPLACEMENT EMPLACEMENT-METHOD"'Industrial/Commercial FROM TO
o it. 20 fh
iMoniate ®®—
Non-Water Supply Well:
021111111
Recovery
1111111111111111111111
��1V1°nit°ring ®�— ..,:• _ '-t,:4 rv-[
Injection Well: D Groundwater Remediation
i�'19".'.SAND(GI2`A.�?EI..EACR"rt�•;7iea'Isle'+%'•`'.: "•EMPLACEMEPIT METHOD
"'Aquifer Storage
Recharge FROM T©
DSalinityBamer
"'Aquifer Storage and Recovery �j lStormwater Drainage
imminiimis
*Aquifer Test ®� . :._: ;•:-s:r..I:C.
�ISubsidence Control •`�;=�"°-
g;,20 D 1T1N • size etc.
(�Experimental Technology C:I O;G attachDESi 1tIP TONecooli r,hardness,
Tracer FROM
TO DESCRIPTION color,hardness,soil/rock A.e
"'Geothermal(Closed Loop) lain under#21 Remarks) ��
Return) Other(explain r
Geothermal(Heating/Cooling � .`� ft• _ •
Completed: Well INft �l G{J MP
[� —
' 4.Date Well(s) �
5a•Well Location: C s4 w __
Facility ID#(if applicable) I. ME
Facility/Owne Name 'z /� r
,City,and Zip ______7_:_________ ii hi II 2rE1 :CR
Physical Address
n o(Vt S�
Parcel Identification No.(P)N)
County degrees:
5b.Latitude and longitude in degrees/minutes/seconds or decimal de gr 22.0 cation:•
(if well field,one latllong is sufficient)
35. N • Date
Signs f i•feed Well Contractor
r Temporary I herebycertify that the well(s)was(were)constructed in accordance
6.Is(are)the well(s)kpermanent o By s rug th rat,
with ISANCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards'and that a
Is this a repair to an ousting well:
If
Yes or ° copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and expl
ain the nature of the
23•Site diagram or additional well details:
repair under#21 remarks section or on the back of this form. You may use the back of this page to provide addition n sites detailsy or well
Closed-Loop the same construction details. You may also attach additional pages
c.For Geonron only 1 GW-1 is ned. Geothermal Wells havingf wells
construction, 1 is needed. Indicate TOTAL NUMB gUBMl'TTAL INSTRUCTIONS
grilled:s
9
d�1 (ft•) 24a.For_ Submit�form��30 days of completion of well
For Total well depth belowd land surface: 3@200'and 2@100') construction to the following:
\.
Static
c wells list all below topoi,#erent(example- 5 —(ft.)
Division of Water Resources,Information Processing Unit,
10.Static watera level below of casing: 1617 Mail Service Center,Raleigh,NC 27699-1617
If water level is above casing,rose"+" form the in 24a
6 (in-) 24b.For Inie Rtells: In
addition tofor sendingiin the3 days to the address of 24a
11.Borehole diameter: above,also submit one copy
well
rotary construction to the following.
12.Well construction method: Injection Control Program,
• 0.e.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,Underground
1636 Mail Service Center,Raleigh,NC 27699-1636
WELLS ONLY: the form to
FOR WATER SUPPLY of this form within 30 days of
Method of test: air pressure 24c.For Water Su 1 &In ection Wells: In addition to sending
13a.Yield(gpm) the address(es) above; also submit one copy health department of the county
s ' �7 completion of well construc
tion to the county P
granulated chlorine Amount: where constructed.
13b.Disinfection type: Revised 2-22-2016
North Carolina Department of Environmental Quality-Division of Water Resources ,
corm GW-1