GW1--05310_Well Construction - GW1_20240906

.1
WELL CONSTRUCTION CR�ECORD(GW-1) 3 For Internal Use Only:
1.We Contractor Information: /�PJ' / 7 '�
6I)t1ct 540 /II// 14.WATER ZONES.
FROM TO DESCRIPTION
Well Contractor Name /�
YJ ft. ft. )'__,� _ )'� .e /,GCS/d /
ft ft.
//�L/fa) j Gl3l.T J—/�V `✓34 l ,S r
NC Well traitor Certification Number 15.OUTER:CASINIG{for'm(u1i1 caned ivelli)ORLIIVER'(If ap lleahle).
` i /'�/� D�`/2! 1 //Il� FROM T DIAMETER THiCKNESS `MATTERIAL
/ l v "tf / �/ {I'f ft _ 41 ft. 6 in. i�;t, �L ci1
Company Name ✓v ✓ J
16.INNER'CAsaiflG UR TUBING:(geothermal:clased-loop).
2.Well Construction Permit#: 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.
1 Well: 17.SCREEN.
Water Supply Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural II MunicipaUPublic 0 r- ft. in.
I Geothermal(Heating/Cooling Supply) [,Residential Water Supply(single) ft. ft. in.
[ Ind 'al/Commercial OResidential Water Supply(shared) I&GROCII' "-.
I/ '
gation FROM TO MATERIAL EMPLACEMENT METHOD AMOUNT
Non-Water Supply Well: D ft 7 ft. 43 TLIrfrb 6ruI �/ --TMI/
Monitoring Recovery rt. ft. // I•Ai /y r 5
Injection Well: ft ft. tr
Aquifer Recharge InGroundwater Remediation
19..SAND/GRAV.EL'PACR(IfapPlliable) '
0Aquifer Storage and Recovery °Sal inity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ID Aquifer Test []Stormwater Drainage rt ft.
a Experimental Technology [Subsidence Control ft. ft.
[Geothermal(Closed Loop) Tracer 20.DRILLINGI':OG(ittieh.id'ditionil sheeislfnee/isar l' '
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(cot hardness,soil/reek tree,vale size,etc.)
4.Date Well(s)Completed: / A Well ID# 3
'ilP ft. L 3 ft / 4
/)2J1Lø1
WeellLocation:: i /� 7� f- 0 ft ,/22 ff. (,/l PT)1 c 5 ih 1$/f
d //e // h ,L//►" c v//s' ft. ft \i -
C..-.t 1s
Facility/Owner Name F ility ID#fif applicable) ft.
1133,g.4l))j T.�,' ICCC ft,1140)7P/7 ft. ft. SEP 0 6 2024
Physicpl A ss,City,and Zip ft. fc P',.',
LIR l Pi 21.RE1IfAItIG4' 1 n / Jam/ ' T�..
R� D �i 11/7�/l ✓✓""`__//__ (�
County Parcel Identification No.(PIN) �J � s� /
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3 •y " e S.S N I. yl e/, W AlA -/%7444, 30 -g)2i
6.Is(are)the well(s) 'ermanent or [Temporary Signature of ified Well Contractor Date
� By signing this form,I hereby cert/fy that the well(s)was(were)constructed in accordance
r!"v
7.Is this a repair to an existing well: DYes or with ISA NCAC 02C.0100 or iSA NCAC 02C.0200 Well Construction Standards and that a
If this/s 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#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: /Yj SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ,v `2 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 r@200'and 2(4100') construction to the following:
10.Static water level below top of casing: 33 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+Q 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: V (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
�,� �7r� above,also submit one copy of this form within 30 days of completion of well
,
12.Well construction method: 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: f` 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 4D Method of test/)l✓ t6 f/ 24c.For Water Supoiv&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: �� Amount FJ l^f �� 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