GW1--07360_Well Construction - GW1_20231113

WELL CONSTRUCTION RECORD(GW-1) Print Form
For Internal Use Only. �--- -"' -� �___ :-,:
1.Well Contractor nformation:
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14.WATER ZONES I
Well Contractor Name FROM TO DESCRIP ION
W
• a.D.0 ft. ft
NC Well Contractor Certifi tionnNumber A, it ft tl �1 c�e�
e 0. 1„ 'Ktl`•IN� 15�tiFR^+caeie 1 _
FROM TO - r D MATERIAL
Company Name ft fr. '� in.
16 INNER a 5c11 lip PO Ci
2.Well Construction Permit#: CASING OR TUBING(geothermal dosed-loop) - •
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) FROST ft ft.
DIAMETER THICKNESS MATERIAL
It. in.
• 3.Weil Use(check well use): ft. FL in.
Supply Well:
17.SCREEN '
AgricWaterultural DiMunicipal/Public FROM TO 9 DI METER SLOT SIZE THICKNESS MATERIAL
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) I(0.5 ft 31 t a ` b I SG 110 y�'
Industrial/Com mercial ft ft in.
Residential Water Supply(shared)
Irrigation 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft
Monitoring Recovery OG its 5 C°N��,�� � Re l e
Injection 11,1 f 'ti'lfr' nitre ileWtle
Aquifer Recharge DGroundwater Remediation ft. it
Aquifer Storage and Recovery E3Salinity Barrier 19•SAND/GRAVEL PACK(if applicable)
Aquifer Test FROM TO MATERIAL EMPLACEMENT METHOD
OStormwater Drainage '1115 ft 31.5 ft t}. '6 g(it- (1 ,( ie.
Experimental Technology Subsidence ControlC!x
ft. ft
Geothermal(Closed Loop) OTracer
20:DRILLING LOG(attach additional sheet*ifnecevary)'Geothermal(Heating/Cooling Return)- Other(explain under#21 Remarks) FROM TO DESCRIPTION
DESCRIPTION(color,hardness soiU`ock}ype grain size etc.)
O f I dtlf: ft
4.Date Well(s)Completed: ' 6. 3 f p _
•. ••Well-ID# f '1� �T� / ft ft
5a Well Location: 3 I is " :y- ''TAP.
`7�1�W N G Rey
A I 5 J
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Facilify/Owner Name ..-.. "
Facility ID#(if applicable) ft.: ,. f�
lea-b. �.c. -
Physical Addiess,City,'and Zip
UR.5 a'I l fdt
4 c ti,
county -. .-. ... ._. .. 21 REMARKS . . .
Parcel Identification No.(PIN)
NOV 1 7(173
Sb.Latitude and longitude in degt eeslmintifeslseconds or decimai degrees:
(if well field,one Iatt long is'sufficient)
36 . l�l l l N $ a b 1 �. 22. ertification: 1,
D., j 1:
W :c J.
6.Is(are)the well(s) Permanent or Temporary Signature of Certified Well Contractor `
Date
Yes nor_ No By signing this'form,i hereby certify that the i+ell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: . with 15A C
If this is a repair,fr11 out known well construction information add explain the nature of the copy of thirecord hasbeen provided to the well o wne�e11 Construction Standards and that a
repair under 1111 remarks section or on the back of this form.
23.Site'diagram.oradditional 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 GW 1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary. ..
drilled:
9.Total well depth below land surface:.t 3116 SUBMITTAL INSTRUCTIONS(ft)For multiple wells list all depths tfd/9'erenr(example-3(a�ri00'and 1@l00') 24a. For All Wells: Submit this form within 30 days of completion of well.
construction to the following: _ -
10.Static water level below top of easing: qq• _
Ifunrer lever is a r e below
use (ft-) Dii+isioii of Water Resources,Information Processing Unit,
G fr - -
11.Borehole diameters` • _..v..,. _ (in.) •
. ... 1617 MailService Center, _
Borehole',d °t: t IItaleigh,NC 27699 1617
24b.For Iniection-Wells: In addition to;sendin the form to the address in24a•.-12.Well.constivction meWod: above,also submit one co g
�9� .
PY.of this-form within 30 days of completion of well
(ie.auger,rotary,cable,direct push,etc.).._- consimction to the following:
:Division of Water Resources,Underground Injection Control Program, '
FOR WATER SUPPLY WELLS ONLY
. - - -'.-1636 Mad Se"rylce r ice Center,Raleigh,NC 27699-1636
13a.Yield(gpm) • - ' ;Method of test:'•'` ` • 24c..For Water Supply&Injection Wells: In addition to sending the forni to -
-
136.Disinfection type .-,:..,. . the address(es) above, also submit one copy.of this'farm within 30 days.Of
,Amount: completion of well construction to the icounty health department of the county
where constructed
Form Gib-1 North Carolina De
partment ofEnv ronmental Quality-Division of Water Resousees
Revised 2-22-204