GW1--06186_Well Construction - GW1_20241021

i
1 -- Printfor'in
WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only: r ' r".."--'
1.Well'Contractor Information: _ 1 q �c)tt'' 7 I ,
I
p- .3 lent/1
'14 WATER'ZONES __S.'
i ,FROM - TO DESCRIPTION
Well Contractor Name
i? .t� � ��' ft. ft, - "G, 1 p .490- •
NCW(ell1Contrac�t@ory Certification
fNumber ��� 15'.UDTERCASIN (foFni lipase&""wells O LINER ap licabe
/�/ I /'�J-// f , /� ' TX/6
4/ FROM TO I DIAMETER THICKNESS MATERIAL
e I tf P,/ t/7 ( (lu/!/ C s Ct. . 3 t. .in. , 3 25 bp); 5y j
Company Name ,
/��� /1��� 3"CINNE&CAS Gr: R'TUBING(Aeotheimel,closed-loop) ' •
2.Well Construction Permit#: / /'/� FROM TO 1 ' DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,eta) ft. ft. ,in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: =L7:?SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial i4en',tial Water Supply(shared)
r :�Res :'18,:GROUT
g ? 1--,a'' FROM T MATERIAL EMPLACEMENT METHOD&AMOUNT
li ation I y C, r, . ,
•
Non-Water Supply Wlell: II �'ft. � / , p 'c ' :.) .5p
Monitoring l [�f ecovery ft. ft. (•
Injection Well: :_t,tlr i
Aquifer Recharge F...:•--.<<•: Groundwater Remediation ft ft. - IT 1� ��f+�,�7
lCr.�• "' ' :'19.SAND/GRAVEL PACK(if applicable) ' -- .
Aquifer Storage and Recovery �'` Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft. ft.
Experimental Technology BSubsidence Control ft. ft. {
Geothermal(Closed Loop) Tracer ''20:'DRILLINGLOG:(attabhedditibnalsheeteIfnecessary)'.• --
FROM TO DESCRIPTION(color,hardness,soil/rock type,gala size,etc.)
Geothermal(Heating/Cooling Return) IOther(explain under#21 Remarks) ft. ft "`
4.Date Wells)Completed: Well ID# it s' ft. 0 47r h/1 rile-�f�/
5a.Well Loc lion: i-mR 2-A,rrf ep PA'i/ /1 3 ft. 3 2 ft. /'PeJr
kg,rP11re. (1N).r 3 7 3 7 ft. .5 4ft. &t '/1 ,/ 4)//4J 77.
Facility/Ownet�Name II , Facility ID#(i applicable) ft. l ft.
1,�i/9-C8 .PW/li9 /re P) lvv 4. .oil "e. ft. !ft.
Physical,Address,City,and Zip ft. ft.
In "1''s/ I 21'a REMARKS
County ' r• Parcel Identification No.(PIN) (O) ' f ,e• -,f r� ) .
Sb.LatitudJand longitude in degrees/minutes/seconds or decimal degrees: 0 ep ! 5'/ ,e; I'1 r "
(if well field,one lat/long is sufficient) 22.Certification: I
3 511)-Lr a 6)/2N 938 'O.p w Aii4/,'J,„e> 9..-,?,5-,-,72-I
6.Is(are)the wells) ermanent or I' Temporary Signature of Ce ' ed Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or No with ISA NCAC 02C.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 ben provided to the well owner.
repair under#21 remarks section or on the back of this form. I
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 etails or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessay.
drilled: SUBMITTAL INSTRUCTIONS , i
9.Total well depth below land surface: I 44 1 (fL) 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'and 2 100) construction to the following: I
i
10.Static wager level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is Above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Bore>tnole�iameter: c (' 24b.For Infection Wells: Ia additign to sending the form to the address in 24a
I ��/ ���� above,also submit o e copy of this form within 30 days of completion of well
12.Well construction method: 111 construction to the folljwing I
(ie.auger,rotary,cable,direct push,etc.)
II Division of.Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:1 1636 M sil Service Center,Raleigh,NC 27699-1636
R / r I
13a.Yield(gpm) -J '°. Method of test: �s 24c.For Water Supply&Infection 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: di-1, completion of well construction to the i county health department of the county
b where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016