GW1--00105_Well Construction - GW1_20231228

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
1.
J V S"\ kefecs 5 14.WA1'ER°ZONES ?'' . f':. :" ::* .;• :, 'x ?. t 1
Well Contractor Name V FROM . TO DESCRIPTION ;
ft. ft. '
U l g( l� :
ft. .ft.
.
NC'Well Contractor Certification Number
15.OUTER CASINGOM r in a ul cased wet[s)OR LER'(f ap Lca6te)\,`A _-./ 1 ��I t45 .. ._ FROM TO DIAMETER THICKNESS MATERIAL _
yV;.l u��f L/�/' {( ft. ft. < 1 ; in.
Company Name l
.. ...
'•16.:INNER CASING'OR`TUBINGi(geothermal'closedrloop) : S,:,,i,,n ` w ..
2.Well Construction Permit-#: - 7 a?a 7. " I. Pk* CI'. ' 'FROM TO DIAMETER . THICKNESS . MATERIAL .
List all applicable well construction permits(i.e.UIC,County,State, Varia/ice,etc.) A. '}-ft. d9 V
I O ft. , 'll tn. • , e`C .
3:Well'Use(check well use): • ft. O ft. !' 1, 1n. 'V l
Water Supply Well: 17.-SCREEN . ex, ... s.',, g r, ;''•: ez, t, II ..
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ' 1 o ft. 5 ft. it ;in, �,l fiUt
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. .in: fv
Industrial/Commercial OResidential Water Supply(shared) -is:.GROUT , • 1' '_ - _• _: .
Irrigation FROM TO MATERIAL EMP ACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft, gp ft. 6rtit�ooti fr......
vvr
Monitoring 0Recovery ft. ft. T (((
Injection Well:
ft. •- ft.
Aquifer Recharge *!Groundwater Remediation
Aquifer Storage and Recovery �JSalini_ Barrier „19i.SAND/GRAVEL:PACK(ifapplietible) - ` ' x? ,,.g . jai"•='.
q g tY FROM TO MATERIAL • EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage aVS ft. ias ft. Sc.4. tkv an.4r I
Experimental Technology *Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer :,20 DRILLING%CiG(pttaehidditiorialsTieeihifnecessa li.' .,k•spe. -_:. i",-'•,-
Geothermal(Heating/Cooling Return) (explain 1 Remarks) FROM TO DESCRIPTION(color,hardness,soiUrock t pe,grain size,etc.)
( b g Other ex lain under#_
ft. ft. i R' ti.-r'- c. -e.-
'ate.1 v, ,r
4.Date Well(s)Completed: i f-a)-23 Well ID# ft. ft. ;
ia.•Wc11 Location: .
ft. ft. Di.(: 2 S. 2023
rt ft.
04 5
Facility/Owner Name ki " 'Facility ID#(if applicable) ,goo,ft ^ 'ft,. .,bin�. i le--- ('„;zi j
C!!AA (a ft d ft. ��{
Physical Address,City,and Zip
Ige.t.ge+- .21.REMARKS.. .l ...' .n,.:...... `t.;.:,-
County Parcel Identification No.(PIN)
•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: --
(if well field,one lat/long is sufficient) ' 22.Certification: '
"S5 '34, 3a77 N -26° P-1,`4217 W 1 • 11-.21-.23
6.Is(are)the well(s)!l, IPermanent or Temporary Signature Certi dwell Contractor' Date
By signing this rm,I hereby certifj.1 that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or EiNo with 1 SA NCAC 02C.0100 or 1 SA 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 cop!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:
3.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: SUBMITTAL INSTRUCTIONS '
/�
9.Total well depth below land surface: �}0�5 (ft.) 24a. For All Wells: Submit t1i'is form within 30 days of completion of well
For multiple wells list all depths if different(example-3 200'and 2@I00') construction to the following: 1
i
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"-" 1617 Mail ServicelCenter,Raleigh,NC 27699-1617
i. It
11.Borehole diameter: 7 �/cl (in.) 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: 0 Y construction to the following: j
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service1Center,Raleigh,NC 27699-1636
13a.Yield(gpm) .D Method of test: Puv.±0 24c.For Water Supply& Injection Wells: In addition to sending the form to
1x the address(es) above, also subinit one copy of this form within 30 days of
13b.Disinfection type: MIA µ Amount: 'U.s. 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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