GW1--08126_Well Construction - GW1_20231215

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' WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
I1.Well Contractor Information: I io t
I
, jcJC? '(.J0.AkAthey 14.1VATERZONES I 1 'M DESCRIPTION
1V'ellCaatmetorName / FRO , TO
_ 30 rL :co tr. i
31s8- A - I
NC Well Contractor Certification Number IS.OUTER CASING(for multi-eased wells)OR LINER Wan lioable)
�r !!���-ke /, 1 U FROM TO DIAMETIER' THICKNESS' MATERIAL
Company Name y (/�/ ' p / [t. 3 O R• f f I in. 11 0 fl()C
�J f i6.INNER CASING OR TUBING(geothermal closed-loop)
2.Nell Construction Permit 11: S�)d),� /��� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ur!lconsuuaion permits(8e.UJC.Count':State.Variance.etc.) N fl. ln.
3.Well Use(check well use): ft. In.
Water Supply Well: FROM REE17. TO DIAMETER SLOTSt7E THICKNESS MATERIAL
Agricultural QMunicipallPublic 30
tt. S-Q fl. hi.
m !6 lin Roc
Geothermal(Heating/Cooling Supply) 1idential Water Supply(single) R. IL in.
Industrial/Commercial fRcsidcntial Water Supply(shared) 1&GROUT
irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
• Non Water Supply 1Vel1: , R. go ft. p r CX j r
- Monitoring - -.--- - - -f Recovery - - - -- - :•.a.--- --ft, •= -f- + --- , V-+ t-3 --_ - -
• Injection Well:
D. rt.
Aquifer Recharge 0Groundwater Rcnrediation 19.SAND/GRAVEL PACK Of applicable)
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL MIPLACEM ENT METHOD
Aquifer Test DStarmwatcrDrainage AO n. TO H, POVif ,
Experimental Technology IjSubsidence Control • ft. ft.
Geothermal'(Closed Loop) : - • OTracer . 20.DRILLING LOG(attach additional sheets if necessary)
FROM I TO DESCRIPTION(radar,hardness.soillroek brae.wale du,etc)
Geothermal(Heating/Cooling Return) ^ Other(explain under k`21 Remarks) IL,
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4.Date Well(s)Completed /0`31-a-3Wcll IDU ""'` -?J(� -ft' �-Q ft f et . ed.:- Q
Sn.Well Location ft, .ft...
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lat + ii f(-
Facility/Owner Name .-. --• Facility IDS(ifapeticable) a: n• " • :�1, f - '.1 : " •
7 6 7..3 /U,c.•'J-iw IIIv4TtA:i, n c. [t. [t. nr-r 2n'y
Physical Address,City,and Zip ft. rt. 1".
P6ZTT • 21.REMARKS , . ItliOli ^:i-'�'•:'! 14...;
County • Parcel Identification No.(PIN) J eA y_ e -\ cse< y�v"r'o&r
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1
Orwell field,one 1atloag is sufficient) 22.Certification:
_35i 663 41106 N ~72 6. 763 3 3 1V ► ' /0-31 3
Signature of Ccrtiacd 1Vell aarrOetar '? Dale
6.Is(nre}thewcll(s) crmanent or Temporary. i _ -
- _ By signing this form,I hereby cerr j.that the well(s)%s s(were)coniimctcd in accordance
D 7.Is this a repair to an existing well: Yes or • with 15A NCAC 62C.OJ00 or ISA!.'C•IC 02e.0200 it'li.Coiutrnctipn Standards and that a -
6rthis it a repair,Jill an moon wit construction information and explain the nature of tire. copy afildr record bat.been provided so Ute nr/owner.
repair under 121 remarks section or on the boob of this form. .
23.Site diagram or additional well details:
8.Fot Gcoprobe/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 I GW l is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 'ems SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 310 (fit.) 24a. For All Wells: Submit phis form within 30 days of completion of well
For multiple walls Ilse all depths((d(/tcrenr(example.30200'and 2 a1100') construction to the following:
10.Static water level below top(leasing: /0 (1t.) Division of Water Resources,Information Processing Unit,
{(tmtcrlercl is above casing.urr•'+`� 1617 Mall Service Center,Raleigh,NC 27699-1617
1I.Borehole diameter: \+.S (in.) . 24b.For infection 1Vells:..In addition to sending the form to the address in 24a•
--' ..-•• A • ",•�r above,also submit one copy of Ibis form within 30 days of completion of well
12.Well construction method: • • �� I"`r construction to the following: i - - , ... -- -.. . r . ..
(i.e.auger,mlary,cable;direct push,etc.).. .
Division'of Water Resources,Underground InjcctiOii Control'Progran,,
FOR WATER SUPPLY WELLS ONLY: ^ r - - I636 Mail Senlce Center,Raleigh,NC 27699-1636-._ ___ _ -
13a:.Yield(gpm) 0 Method of lest: 1"'i 1 i 24e-:Ser'Water Supply&Info ction Wells: In addition to sending the form to•: '
• lhetaddress(cs) above, also submit one copy of this form within 30 days of
13b.Disinfection type:0140e i1 Q. Amount: 3 O ' '• .,. ;completion of well construction io the county health department of the county
where constructed.
.y v
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Form GW-1 Nord'Carolina Department of Environmental Quality•Division ofWalcr Resources Revised 2-22-2016
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