GW1--06193_Well Construction - GW1_20241021

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WELL CONSTRUCTION RECORD (GW-I) For internal Use Only:
1.W,II Co tr tm•Inf ra ion: •
Z/y/�/y//'�1 •
1.4::WATY•1R�ZOLVE`5�=�i..,:.�.:,'a:=�°�; .;: :' `.�. ..- .
FROM TO DESCRIPTION
Well Co
ntractor Name [ t /. L/L)/ft, / ,.:/'//,
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NC'Well r gtorC rtificati Number ]� .///�-+ 15.:6UTCR�GASING(fo►:millft=tie9PdsWi~lis):QR'I;A`1Pr1I*(if'op�7taaii)e}i:.:��'i>:'-'i,- '
I ' I 0 ! /� FROM ft, TO ft, DIAMETER in THICKNESS MATERIAL
Company Name l�
•••��� /� . 16,INNBR"CASING It T.UBING(gepfNernialralosetLlpop)
2.Well Co.struction Permit Mil/�p C/0_5 PROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.•UIC,County,State,Variance,etc.) 6 ft. /71_, ft, 6 /�f in V?--/c- p V�
3.Well Use(check well use): I • ft. (( f ft. , in.
.
Water Su t Well: •i7„SCE•N:RE .:: . -__ ) _ ~•-
pp
FROM TO DIAMETER SLOT SiZE THICKNESS MATERIAL
1111 Agricultural DMunicipal/Public ft. ftl In.
1 Geothermal(Heating/Cooling Supply) Elliregential Water Supply(single) ft. ft. in.•
*Industrial/Commercial fD'Residential Water Supply(shared) srGROUT P =+
I }i Irrigation FROM •TO MATERIAL EMPLACEMENT METHOD,&/AMOUNT
Non-Water Supply Well: G ft' :f / ft' aer../✓<A9r•'. d/7�7(i- >/ . //6'l/V
ill Monitoring I I Recovery ft. ft. ! —V 0 h/ -
Injection Wcll: ft, ft, • ✓
"'Aquifer Recharge ]Groundwater Remediation
II ''•19.SAND/GRAVEL;PACK'(ifiappliciibie)-i..e«,__=:_i`:•:•:.a:..:: ,.;,:-::::_,..:. .
*Aquifer Storage and Recovery DSalinity Barrier FROM TO ( MATERIAL EMPLACEMENT METHOD
II Aquifer Test IStormwater Drainage ft. , ft. r 1
a Experimental Technology IOSubsidence Control ft. ft. l
St Geothermal(Closed Loop) *Tracer 211.1)RILI;II.!IGLO:G4{tittiibh'aililitlonulibiets'If ediiii5ry•.)=a:_-:<f.:::: •_.•-'. •
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FROM TO DESCRIPTION(color,hardness,soWrock type,gran size,etc.)
111 Geothermal(Heating/Cooling Return) i, I Other(explain under#21 Remarks) ft. ft.. U ' /, 1
(� / /a� �/ G r1,= h UAL i i 1)
4.Date Wells)Completed: ! `�/;--)7L Well ID# (.�/i'/�'• / ? it, , L) fL /A,v/4(/ ('>-7 iZ/f i
Sa.Well Loc�tion: .7/.. ft. •,7), s--ft. / --r11/44`/, /7/7 0 l� ,
;�i e. 1 .+1.)Ci k.1,1/7- .-, 1.
Facility/Owncr3Namc Facility iD#(if applicable) e� —'ft. f/1G47ft. %7/' :�/(-T 4/7n �(c:---
/3;Y ///'.'./71 .i(//'17/-?iVc:::t-R0/21,/,,f--v„,A./pe:4 6 "Ta :;.,
Physical Addss,City,and Zip ' ft. i ft.
.. 21..RJ MARKS: .. (. I.c 0 t_.
County .--/ Parcel Identification No.(PIN) .� „+il3}
ir`:.:, ..,...
5b.Latitudeland longitude In degrees/minutes/seconds or decimal degrees: I i. :-'':.0
Orwell field,one Iat/long is sufficient) • 22:Cc tt cation: • �jf
t�—:G-: 1 S i'�i, Cyr�(O N i � t CJ`. `71 /,.�G/ W "/!/� r� v 4'� ,o��i... J %/✓7
41
�,�, Signature of Cerl ted Well Contractor ' Date /
fi.rs(are)the wells)i.�'Permanent or f_'NTemporary
•
By signing this form,I hereby cerltfj&that the well(s)was(were)constructed in accordance
7.Is this a ref air to an existing well: DYes or In1Qo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repai•,Jill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21II remarks section or on the back of this farm. 23.Site diagram or additional well details:
8.For Geopro'Ue/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 ifnecessary.
construction,only.1.Gy✓-pis needed. Indic�te TOTAL NUMBER of wells 1I
drilled: j4 / `'% SUBMITTAL INSTRUCTIONS l
9.Total well depth below land surface: / %A c Gi (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iild perent(example-3 t@t 200'and 2 tJ100') construction to the following:
10.Static water level below top of casings f S`n� - (ft.) Division of Water Resources,es,Information Processing U )t,
•If water let.:is(above casing,use"1-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole Ufameter: l//;� (in•) 24b.For Injection Wells: In addition to sending the form to the address in 24a
t - above,also submit one copy of this'form within 30 days of completion of well
12.Well eonaj�ruction method: /•'R A"/R/Z LV construction to the following:
(i.e.auger,rota ,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
/t ' / i f 24c.For Water Sutibly&Infection Wells: In addition to sending the form to
13a.Yield(gpm) _� Method of test:rt/Q / //f
the address(es) above, also submit lone copy of this form within?,30 day: of
// r!�{, �! completion of well construction to fhe�county health department of the county
13b.Disinfection type:r'l'I G'� �///fG� Amount: t where constructed. l ! I •
i
I L " Revised 2-22-201U
Form OW-I North Carolina Department of Environmental Quality-Divisionof'Wn terResources !
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