GW1--00164_Well Construction - GW1_20231229

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: . .
1.Well Contractor Informatio
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i-&! "'A l2`—H— 1"4')X!ATI112:' HES �. s
Well Contractor Name s. FROM TO DESCRIPTION
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Well Contractor Certifi Lion Number
I5i;0ximattABING'(Lsaitlilti+c'ia•welfs)IQRI)iNER-0ep 11ca0te),
JFROM TO DIAMETER THICKNESS MATERIAL',Le', k�Qi1l 414,01) Lo . Tn.( r • tt. ft. 61 in.
Company Na A f� ;..16•.INNER CASING DRV INGz(geothermaltcloiiai:loop) = .
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2.Well Construction Permit#: a I FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. In.
•
3.Well Use(check well use): ft. ft. In.
'i;17 kIltEENI?. _ :
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural EjMunicipal/Public ft. ft. I In. i
Geothermal(Heating/Cooling Supply) %:.:.Residential Water Supply(single) tt, ft, ' In.
Industrial/Commercial OResidential Water Supply(shared) ;;1 .OR0 r.,, \•v,. `•,..`-
Irrigation 1 , FROM TO MATERIAL EMPLACEMENT METHOD&AMO T
_ Non-Water Supply Well: . - 0 ft. �O ft' pert-1'�11J�e- ).C.b 5 1)Ikre-d
Monitoring Recovery ft. ft, LI
Injection Well: ft. ft.
Aquifer Recharge .Groundwater Remediation ;19 SANDIGIVAMEL PACK(If?appl[eebte) = °` ; -
Aquifer Storage and Recovery. OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stonnwater Drainage ft. ft. ,
•Experimental Technology • Subsidence Control ft. ft. I '
Geothermal(Closed Loop) Tracer t 20::I)RILL1NG L•QGi(pttachledditloiealtslie€te if neaessery) --:: _•
FROM TO DESCRIPTION(color hardness,soll/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) d ft. / q ft. c)y ( 1 L J
�1 tP Lt
4.Date Well(s)Completed: y
•/A-AC A-Well ID# /70 ft. 14� it. . y, i .f.
(( ft. T It. — ; �;•-
Sa,Well ocation: _
-tlieS 045 5 .
Facility/Owner Name Facility1D#(ifapplicable) ft. ft. nl- I. 9 .Q 2,9Z
� z 6i11i1�b�1 , ft. v, '� ' , M
Physical Address,City,and Zip ft. ft. 'I, •a t ' .
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County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one let/long is sufficient) 22.Certiflcation:
35-.20..604 N ' 91. 975U4 W /6,2- /2 --,1-023
SignaturegfCertified Well Contracto Date
6.Is(are)the well(s)tePermanent or Temporary ;
By signing this form;1 hereby ceril that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E3Yes or 'sp. with ISA NCAC 02C.0100 or ISA 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 copy alibis 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:
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 details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed.•Indicate TOTAL NUMBER of wells ;
drilled: S SUBMITTAL INSTRUCTIONS . •
9.Total well depth below land surface: Or (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For midtipie wells list all depths If different(example-3Qa 200/'and 2®100') construction to the following: I
10.Static water level below top of casing: !O 6 (ft.) Division of Water Res Iurces,Information Processing Unit,
If warer level is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diarheter: /S 4/ (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: rotil e y 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
13a.Yield(gpm) Method of test: a../>^ 24c.For Water Supply&Injection Wells: In addition to sending the form to
` the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: &la rill -. Amount: ). C/./•Js completion of well construction to the county health department of the county
where constructed. 1
Form GW-1
North Carolina Department of Environmental Quality•Division of Water Resources Revised 2-22-2016
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