_Well Construction - GW1_20230315 (15)

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
t �
14.WATER ZONES i
Well Countractol Name FROM TO DESCRIVrION
S5 fL 07 ft-
NC Well Contractor CenificQrIionNumber ^ 15.OUTER CASING for multi eased,»ells OA LTNEA if a Iteable)
FROM T� DtA.1tETER �Tn•/C/l.'NlF/SS r1ATERSA/L
!! �t 1/ r --i`•'-- �{ 1 r-��t f n. , ll. in. ✓"h Y J t C�
Company Name �� Qwa-lom /
16.1NNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit 14• FROM TO I D1A11tE'fEA I THICKNESS MATERIAL
List all applicable well construction permlis(i.e.UIC,Couny,Srnte.Variance,elm) It. fL In,
3.Well Use(check well use): It. ft. In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE T1110MESS MATERIAL
Agricultural C]M lcipaVPub(ic .-^, n. l ft. In. J L15/6" 6 uhw PV L
Geothermal(Hcating/Cooling Supply) esidential Water Supply(single) ft. ft. is
Industrial/Comutcrcial Residential Water Supply(shared) 18.GROUT
In'l alion FROM TO MATERIAL EMPLACEMENT AIMIOD&AMOUN-r
Non-Water Supply Weil: B ft• r;,
Moniforing - _ Recovery fl: - n:
Injection Well: ft. ff.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery [3Salinity Barrier FROM To MATERIAL EnIP El1lENThIETItOb
Aquifer Test [3Stor)waterDrainage � n. J ft. $'a O
Experimental Technology Subsidence Control ff. ft. 1 4
Geothermal(Closed Loop) [3Tracer 20.DRILLING LOG atineh additional sheets If necessary)
FROM TO DFSCRIM ON color,hardness.sotUroeh e. In silt.eta)
Geothermal Heating/Cooling Return) MOther(explain under*21 Remarks) ft. `•� n. G
4.Date Well(s)Completed• -I Well ID1/ tr: �'� tt. r .,a,•,d �.- h
5a.Well Location: n, I ft.
Facility/OwnerName i /FoeilitylDq(if applicable)
n.
Physi ddmess, ity,and Zip ft. ft.
T
44� - 21.REMARKS `
County Parcel Identification No.(PIN)
5b.Latitude and longitude In depvcs/m)nutes/seconds or decimal degrees:
(if well field.one Iaillong is sufficient) 22.Ce rc on: Z_
N W
6.Is(gre)the well(s) ermonent or Temporary %ignaturc en ,cd Well Contractor Date
By sign n it form,1 hereby cert65P that the wells)was(mare)consthiciEd in accordance
7.Is this a repair to an existing ivell: 13Ycs or No with ISA NCAC 01C.0100 or 15A NCAC 01C.010011'ell Construction Standards and dmt a
#'this is a repair,fill ourknown well construction Information and explain the nanere of the copy of thij record has been provided to the cell owner,
repair under#21 remarks section or an the back of this form.
23.Site diagram or additional well details:
S.For Gcoprobo/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page mo.provide additional well site details,or well
construction,only I GIV-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: -7' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 17
/ (ft.) 24a, For All Wells: Submit this form within 30 days of completion of well
For multiple urlls list all depths if different(arample-3@20�0'and 1@100) contraction to the following:
10.Sta6c water level below top of casing: 1 .5 (ft.) Division of Water Resources,Information Processing Unit,
If wnrerinviis above casing,u3e"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (iD 24b.For Injeetion Wells: In addition to sending the form to the address in 24a
tJV�� �� f-� above,also submit one copy of this form within 30 days of completion of well
t2.Well construction method: I !!! /11��� 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 276994636
13a.Yield(gpm) blethod of test: 24c.For Water SuDDIv&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: completion of well construction itoi the county health department of The county
where constructed.
a ,
Fonn GW-I North Carolina Department orFnviroamemal Quality-Division of Water Resources Revised 2.22-2016