GW1-2023-00360_Well Construction - GW1_20230103

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor I,enforma o11. P a.� .m' ♦ D r n
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Well Contractor Name FROM TO DESCRIPTION
4 ft. ft. Ci M
��� L A ft. ft. I,1
NC Well Contractor CertificationNumber
t;1,. t• • 1 1 � n .. ,15(?11T-ER: SIl'1�(Sorjiiui6.,.. Yells) aPP1b�a1s'fe}
FROM TO DIAMETER THICiLNFSS. MAltkW
i] UL 0 v l It ft. fit tr G .
Company Name ;16>;TN1�R; " _. .C`iOIYi'Lt#IiINC�"c" 'eitl[[ermal�[osed7aa.,.K-gip: V�.'�.h�'.<!'�..:�)F
2.Well Construction Permit#: 41
at FROM I TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Count);State,Variance,etc.) ft. ft. fn. ID
3.Well Use(check well use): fL ft.
Water Supply Well:
FROM I TO I DL4IIETER SLOT SIZE I THICKNESS MATERIAL
❑Agricultural unicipal/Public ft. ft. in!
❑Geothermal(Heating/Cooling Supply) ?P"Iesidential Water Supply(single) ft. fL In'-
[]Industrial/Commercial OResidential Water Supply(shared) T3$`iGlt0t12
OIrri anon ❑Wells>100,000GPD FROM TO I
MATERIAL EMPLACEMENT OD&AMOUNT
Non-Water Supply Well: ft. 2• ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. fL
❑Aquifer Recharge ❑Groundwater Remediation a19� APmlGEtA l L3'ACIf'it a"]ic'lie
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMWiT METHOD
❑Aquifer Test ❑StormwaterDrainage ft'. fL
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer '3b..)�I1uLI1+JGI att�chaddtriiiiiatsheeCs']tnecese �: :.d: x ?rF
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) I
FROM TO DESCRIPTION for hardness,soilfrock type,grain size etc.
ft. ft. t7 s6 1
4.Date Well(s)Completed:�A�Well ID# A ft. J Q ft. Ci I
5a.Well Location: ip bi I K,kr ;r b :
hh �a� ���Yf` A � .A ft., Jt
Facility/Owner Name FaciIityID#('(Applicable) fI: ft 'V 22023
31M 5 rK Pr�e��1z�f.F ft ft
PhysicaC."'
, ity,and Zip 1 ftt ft
l ityr I o`}' _...
County Parcel Identification No.(PIN) th frier .5
Q
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ex
N W
6,Is(are)the well(s): permanent or ❑Tempora;Zo
Signa o Certified Well o°tr for Date
By si ning this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ISA CAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the 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:
s_Fnr(25!nn..ni,5mwr nrry,aa.l_r..,.,.,Genfherm2r WON l Sv;..,.th!P.'a-e You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add"see over in xemarxs tsox).'Y ou may also attach additional pages if necessary.
drilled: c.� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: u® (ft.) ,Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200''aand 2@100')
10.Static water level below top of casing: 12.0 (ft.) 24a. For All Wells: Original form,to Division of Water Resources (DWR),
tfwarer level is above casing,use"+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) r 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
sy�^ . , Program,1636 MSC.Raleigh,NC 27699-1636
12.Well construction method: r6 a�.7
24c.For Water Supply and Open'-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where instal ed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing lover 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 0 Method of test. IPV Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount: 2
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018