GW1-2022-07062_Well Construction - GW1_20220722

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: f
I.Well Contractor Information: I j
A TO DESCRIPTION
14.WATER ZONES FRUni 1
Well Contractor Name _
3 ft. ft- 1 f
(> (t, ft. � ti� r it•' t+ ,!-Yi Y'7 �f['rl_..r^.�i/-
NC Well Contractor Certification Number 15.OUTER CASING for multi=cased wells)OR LINER if a cable
S �� J�+ J+ P ' croon. TO DL\Mr•.TER THICKNESS MATER,AI.
ft. ft, in.
Company Name
16.INNER CASING OR TUBING Neothermat closed-laa
2.Well Construction Permit#: FRONT TO DIAMETER THICKNESS n1ATERIAL
List all applicable n•ell con.swuction permits(i.e. UIC.Conn;State.Variance.etc.l 0ft. '�:` ft. in.
3.Well Use(check well use): fr. ft. tu• h
Water S Iv Well: 17,SCREEN
u
pp FAO\i TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_Agricultural- Municipaj/Pubhe-
Geothermal(Heating/Cooling Supply) DiResidential Water Supply(single) ft. J ft. in.
IndustrialiCotnmercial — [pResidential Water Supply(shared) 18.GROUT
lr'r'i ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring QRecovery «$ft. 'l g•R. r36_461�•fC' G.�-�✓rf`� �Ow
InjectionVVell: u�r`/C-r-e�✓+ �I �Iv6�
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Siorage and Recovery DSallllity Bar•ler.- FROni TO MATERIAL F,nIPLACEMENT METHOD
Aquifer Test �IStornnwaterDrainage //eft 'C
. ��-ft. -t�S S'/v nr Uri ro}
V i
Experimental Technology DSubsidence Control
Geothermal(Closed Loop) ❑ITracer 20.DRILLING LOG attach additional sheets if necessary
FROM TO DESCRIPTION colnr,hardness,soillrock t) e, r.,in stte,etc).
Geothermal(Fleating/C'ooling Return) nOther(explain under#21 Remarks) )
- (t. '7 ft, )(�aiL�.QJ , r"L(ii Cslli �sjtil lY _
4.Date Well(s)Completed: --Z'Z Well ID# f O [J �, ft. ,S ft• i�•ro i✓�+- ids �� Sr n7, r�/+! •
/ �j'1211 —
{ ft. �^r" ft. J �G°l�cl� /c-c�i:l2 C` /✓ ���
Sa.Well Location: .1 ]t )J -�_—
Udl/ Uc�r' SQ�iitlL)N�- US/-� t't. fo I., t t-e
----—
Faciility/OwnerlName I Facility IDlitirapplicable)AI
ft. ft.
3(� D �,r/e°J 7 GG�e°�Y�pVF'd^��I✓C' (j✓• ;ec��i�'�G, -- V 1r'---
Plrvs cal Addicss,City and ft
Zip ft. .
/r/,� ti k 21.REMARKS —
NN �a {(1�►t &lOfl Prineos"M` a
County flared Identification No.(PIN) __—DWGV OG-- —
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -- ---
(if well field,one Iatilong is mifficient) 22•Certification:
Ll
6.is(are)the well(sI Permanent or DTempol arp
` lenature ofCctlilied Well Conlraiior'�
BP signing this/brin. I hereb'v certi(i-that the nrUtsl iruc orrrr-)eon.urrd:';<in'..r;+nii•r.
7.is this a repair to an existing well: DYes or JANo with 15.4 NCAC 02C.t)100 or 15A NCAC•02C.02nn)Fell Co,nt;ar;ion Srrr.,da:c•.md fir• a
if this is a repaut fill out known well con.structinn inloruuttion and ea;lain the nature of the. Copt-gfdtic record has peen In oviderd n,the tell onnul.
repair under NJi rrnun$.c.err ria;or on the hock of lhie fin-m.
23.Site diagram or additional well details:
8.For Geoprobe/DOT 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 I OW-1 is needed. Indicate TOTAL.NLiMBER ol'wells construction details. You may'also attach additional pages if necessary.
drilled:_ SUBMITTAL INSTRUCTIONS
9,Total well depth below land surface: _ (ft,) 24a: For All Wells: Subn)ii�this form within 30 days of completion of well
For rrudtiple wells list rill depths ifdi(lm-e„t 1,su,nple-9(ii.200*and 1f«,laP) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water 12esources,,information Processing Unit,
!"water love/is ahnrecaxing.use"1' 1617 Mail Service'Center,Raleigh,NC 27699-1617
11.Borehole diameter:_ --_(in.) 24b.For infection Wells: In;addition to sending the forni to the -
above,also submit one copy bf this form within 30 days of completion of well
12.Well construction method: �r�.vie 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: 1636 Mail Service Center,Raleigh.NC 27699-1636
13a.Yield(gpm) Method of test: 24c. For Water SUDDIV& i nie.-tion Wells. in addition to sending file form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to file county health department of the county
where constructed.
Form GW-I North C'molina Department of l ivironniental Quality-Division of Water Kesourl Revised 2-22-2016