GW1--05663_Well Construction - GW1_20240920

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WELL CONSTRUCTION RECORD(GW-11', . For Internal Use Only: ' A _ •
1.Well Contr tor formation:
Ii)Qt/11 00 it./ , ..._.__ _ ......._
. 14.WATER ZONES
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FROM -TO DESCRIPTION
Well Contractor Name , . , ..
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NC Well Contract r Certification Numirr
0 . , 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
19(.0 t/0010 fry)10 iri:11,14 I IA CID FROM TO, DIAMETER THICKNESS IMATERIAL
13-
, VI- V ir 'V '
16.INNER CASING OR TUBING(geothermal dosed-loop)
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_ , . , DIAMETER 'THICKNESS MATERIAL'
2.Well Construction Pe.rinit#:• , ' . FROM TO
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List all applicable well construction permits(I UIC,County,State,Variance etc) ' ft. . ' ft. . :'' IlL
3.Well Use(check well use): , ft. ft.
17.SCREEN •
ater pply
• , . ' . •
W Su ,Well: , • , '' .
- - FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural' E)M7icipal/Public .
• 14 ft. 55"ft' ,q ' In. ,2C2 _cc 4 5?(1 /armit.
Geothermal(Heating/Cooling Supply) I'DKesidential Water Supply(single).
Industrial/Commercial • ,E3Residentiel Water Supply(shared) iti GROUT
' , - ' •
• I Irrigation .
- FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
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il ft. Ao ft. 0
4'. .-( - 42"V. d(00°..) /0‘.0."-
Non-Water Supply We :
Monitoring.. ' ' ' ' , E3Recovery ' ' •', ft. ,. . ft. _
• Injection Well: , • •
ft. - ft.
Aquifer Recharge le, roundwater Reraecliation •
,.. - 19.SAND/GRAVEL PACK(if applicable)
' - Aquifer Storage and Recovery - EjSalinity Barrier • FROM TO MATERIAL - EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage,' .75-f" ,cr ft. Oti7&44'7 ,• 10"1. .
Experimental Technol.: . 111 Subsidence Control - -' - ft. ft.
Geothermal(Clo -. Loop) - ' III'racer -- - 20.DRILLING LOG(attach additional sheets if necessary)
undFR#21 Remarks)
OM TO DESCRIPTION(c hardness,soil/rock type,grain size,etc.)
4 Date Well(s)Geothermal(Heating/Cooling Return)1 . er(explain
. er ' ,
oli7,
•;' Atil 0-4
. Completed Well Well ID# '' • " _ ...3 ft of,/ ft• , , . • ,..., __ •
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5a.Well Location ' • ,- ' . • ' : - oPa irIP• ,...< 4)4> ',.t,„`is
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---,Neot- cilti , .
. , , .25' Sr ' ,(*(.4 n s
'• Facility/Owner Name. - '- Facility ID#(if applicable) , ft. ft. ,, ,c.../ 4 0 2:024
f/cA.
ft. ft.
tr,-..:,;„,;;,s;i:r-, -..,,.
..1,,,-,. - •,t1 i-k-':.Z
P Addle-4%City,and Zip' - c-,.,
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"ti III 21.REMARKS
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County , Parcel Identification No.(PIN), 5e/f 4t4j bv-)1 '
Sb.Latitude and longitude in degrees/minutes/seconds ordecimal degrees: • •
(if well field,one 1st/long is sufficient) - ' 22.Certificatio . '
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6:Is(are)-the well(s) ' nent---or:-DTemporary '2' --' ' S.,ignaturet" Cer=.:-...7";141:47ell Contractor ' -` Date
By signing this form,1-hereby certify that the well(s)was(were)'constructed in accordance
7.Is this a repair to an existing well: DYes or ElNo ''` with 15A NCAC 02C.0100 or/5A 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#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
You may use the hack 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:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: , .
5:\f"'. (ft'1
' ‘'', 24a. For All Wells: Submit this form within 30 days of•completion of well
. - For multiple wells list all depths if different(example-3@200 anc12@l00)
, - construction to the followin • " ' , '
ll
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'• 10.'Static water level below top of casing:, -. (ft.) Division of Water Resources,Infodnation Processing Unit, '
If water level is above casing,use"4- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: • . - ' . (in.) .
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24b.For Injection 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
.)('A/12.Well construction method: -/Mt. y construction to the following: •
(i.e.auger,rotary,cable,direct push,etc.) , ,
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' 7----"‘ • Division of Water Resources,Underground Injection Control Program,
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.70R WATER SUPPLY WELLS ONLY: ' , , _
`1639 Mail Service Center,Raleigh,NC 27699-1636 , .
!•- ' I3n.Yield(gpm) ii:7-" -, ' -Method of teat:- ,,..,,t- • • - - .. 24c.'For Water Supply&Iniiiction Wells In addition to sending the form to
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-• - • ' / _ ' the address(es) above, also'submit one copy of-this form within 30 days of
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' 13b.Disinfection type (44/dekt Amount ' 3 0 c- ' ' completion of well construction•to the county'health department of.the county
where constructe(4. ' ' , -, ,•
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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