GW1--07777_Well Construction - GW1_20231201

WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only: '. ' I
1.Well Contraolor informa fo :
14.WATER ZONES DESCRIPTION A
. Well Contractor Naast4M q PC FROM ft. a' ��Jlr/
,fir,j ft. r•7 ft.
///��� 15.OUTER CASING(for multi-ram wells)OR LINER(if applicable)
NC Well Conractor C rtificauon Numbei � � , w`,,�/Y1 FROM TO DIAMETER. THICKNESS MATERIAL
N ` 1if1 (l/]�.�1VJ1I`r I'✓�n` '✓/,11Y VVJ 0 ft. dr4/ ft. g in. S+G4ce,„, /,(dam
CASINGCompany Name I� • 16.I NNER ORTUBI NG(geothermal dosed-loop) O''
FROM TO DIAMETER THICKNESS MATERIAL
2.WTI Construction Permit.#: ft• ft• in.List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): 17.SCREEN
Weser Supply Well. FROM TO Di AMETER SLOT SIZE THICKNESS MATERIAL
in, no SG4 fV "[.' .
ni,cipaUPublic fir`Agricultural BIN? v�""ft• /S ft. ; �JiGeothennal(HeatingiCaoling Supply) idential Water Supply(single) J 7 ft. LY ft. dam' in.
Industrial/CommercialR Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ,4, ,A "Y
Irrigation ft. �ft. iL;�',/ � /�yste/�/ /_
Monitor Ing
DReco,..y ft. ft.
Injection Weil ft. ft.
Aquifer Recharge a Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEM ENT METHOD
Aquifer Storage and Recovery Salinity Barnet �y 6r ft. ��e /
ft. Qc.i/
Aquifer Test 0Stormwater Drainage !
Experimental Technology E3Subsidence Control
ft. ft.
Tracer 20.DRIL LING LOG(attach additional sheets ifrte rY) ainsze,etc
Geothermal(Closed L -�) ►' FROM TO DESCRIPTION(color.hardness soil/rock type rF )
il Geothermal(ilea!- g/Cooling Return) ri S -r(explain under##21 Remarks) a it. ft. r*/
ft. ® ft.4.Date Wdl(s)Completed;_._____.__ Well I D# ft. 4...—ft. �
//
5a Well.Location: f 4 ft. . a ft. e �e 1f
ft. �� �
Facility/Owner Name Facility ID#(if applicable �� ft. /(" .-
IOM ve-enuv). vviiti ...l r, if 1
Phy-sichl Address,City,and Zip 21.REMARKS lv tCV 1 `�'
Parcel Identification No.(PIN) y�� a t '"
Calmly L.i t�a L.'�����L`~
5b.Latitudeand longitude in deg e�esfminutedsecondsor dedmal degrees: 22.Certificatio
_--
(if well field,one iadlong is sufficient) • /�,.y���"
N � . W
(�
6.Is(are)the well(s) erm �t orITemporary
SignatureBy stnra -e;:
Well Contractor Date
ng this form,I herebya certify drat the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or l5A NCAC 02C.0200 Well Construction Standards and that a
7.I s this a r epai r to an ecf sti ng well: Yes or copy of this record has been provided to the well owner.
If this is a repair,fill out known well consnvction information and explain the nature of the Site diagram or additional well details:
repair under#21 remarks section or on the back o f this form. 23
You may use the back of this page to provide additional well site details or well
8.For Geo only I PT or Closed Loop Geothermal Wellshavfng the same construction details. You may also attach additional pages if necessary.
construction,,only 1 GVi7-1 is needed. Indicate TOTAL NUMBER of wells SUBMITTAL INST RUCTIONS
• drilled: �
9.Total well depth below land surface: (.� S (ft') 24a. For All Wells: Submit this form within 30 days of completion of well
For.multiplewellslistalldepthsifdifferent(example-3(g1200'tntd'2000') construction to the following:
10.Static water level below top of casing: gP (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: U` (in.) 24b. For Injection Wells In addition to sending the form to the address in 24a
�P above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: .01l/JI' kj 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
Method of test: t 24c. For Water 91polV& Infection Wells: In addition to sending the form to
13a.Yield(gpm) the address(es) above, also submit one copy of this form within 30 days of
Amount: 2 C completion of well construction to the county health department of the county
13b.Df�nfectiori type: . where constructed.
' Revised 2-22-2016
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources