GW1--02032_Well Construction - GW1_20240401

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: '
1.Well Contractor Information: 1 -
I
o S 14 (?efv,e 5 5 14.WATERZONES ;..1
Well Contractor Name / • _FROM TO DESCRIPTION _ -_ •
l,1 r I ft. ft. i .
/I'1L 1 3 S ft. 16 5 ft.
L,,+,e5 d1,
NC Well Contractor Certification Number :15'OUTER=CASING(foimulti-cliseiliwe1140R T;INEW(itap"leiiii e)y
rM [4(/
,u 15 /e.// a f/'t FROM TO DIAMETER THICKNESS MATERIAL
ft.
ft.
Company Name
'16:-INNER'EASING'ORTUBINGWothermalclosed4iiiii """ .V. ''
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Count,State,Variance,etc.) O ft. 1 35 ft. (J in. CAr I iove_
3.Well Use(check well use): ft. 7 1 ft, t f in. J
Water Supply Well 17::SCREEN`.'',1- 1_ .,.'.';iWi-.r?,,.isi:74V - ,.,a .&'f*yr'. Yr':Sx i.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ElMunicipal/Public i 2[ ft. 165
ft. t.( in. ,o3 2— S�� c.f0 t
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) .5''
ft. ft. in•
ndustrial/Commercial D,.Residential.Water Supply(shared) .l8.GROUT: A .. ..; iy.,ii <". . . ..., i `'t` °}, 7g :Yl,m.
Irrigation FROM TO MATERIAL EMP CEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft. D0 ft. eutitim1
f„ , vim
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge OGroundwater Remediation
.19:SAND/GRAVEL•PACK(itapplicable) 4 s ,i;'' ter)...*'`-4"s,', .-.;.•
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStonnwater Drainage 130 ft. /6 5 ft. .5 5c...)
O t+rr-
Experimental Technology OSubsidence Control ft. ft. •
Geothermal(Closed Loop) OTracer 2lYsDRII.L]NG"L'OG(attiiiiiiaaliiaallVie t rgVeessai9jM=' A
Geothermal(Heating/Cooling Return (explain 1 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
( g/ g ) Other ex lain under N_
�'11 ft. ft.
4.Date Well(s)Completed: 2—d t-,g(Well ID# (;;IA/07 r ft. ft. n ' '- r,ii„ 177 r'
Sa.Well,Location
N v-1 ft. ft. R t.L.5,..,j'L.,is V 11..,.L'
ri ev/ ft. ft. APR tl I 2024
FacilityiOwner Name Facility ID#(if applicable) ft. ft. '
ft, fL iTtiOrFti3Gc+t r._�w.rr.,y
1 S30 iUG 306 5 ar�1 �
Physical Address,City,and Zip ft. ft.
6eASO/+-
e21.*REAARKCr'.; -. 4i itS'gk :f _ :=k'•;k`,YeKr ts.ry$:f-,0fi..,,s
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification: 1
3S, gsc7 N —X. '-1305 w
6.Is(are)the well(s)DPermanent oremporary Signature o Certi t ell Contractor; Date
By signin this fat r,I hereby certifj'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or t'o with 15A r CAC C.0100 or 15A 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 of this record has been provided to the well owner.
repair under=?1 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,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: 16S (ft-) 24a. For All Wells: Submit this fonn within 30 days of completion of well
For multiple wells list all depths if different erent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 5' (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"-" 1617 Mail ServiceICenter,Raleigh,NC 27699-1617
/11.Borehole diameter: �14. (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
�/j I above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: Il\�1' "/ construction to the following: ! '
(i.e.auger,rotary,cable,direct push,etc.) l
Division of Water Resource ,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service;Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 72 - Method of test: w w,to 24c.For Water Supply& Injection Wells: In addition to sending the fonn to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: lT K Amount: I I b c completion of well constructions 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