_Well Construction - GW1_20230320 (89)

WELL CONSTRUCTION RECO _ GW 1 For Internal Use Only:
1.IWell Contrac'toor.Information:
" •14.WATER ZONES
Well ContractorName FROM I TO DESCRIPTION
5 O ft q30 ft —0 —
NC Well Coahaetor Ce:tifieatioaNumber ft ft '
IS.OUTER CASING for multi-rased wells OR LINER rf a liable
A., �_ FROM' TO DIAMETER THICKNESS I MATERIAL
Company Name ft ft in.
�/ 16.INNER CASING ORTUBING eothermal elased-Ioo
2.Well Construction Permit 9:A_5 93a G ]- FROM 1,TO I DIAMETrV ITHICIQIESS MATERIAL
List all applfcable well eonstruetton permits a ITT Corarry,State,Variance,era) -�. ft ft C�7 a/ to —rt:17 nJ
3.Well Use(checkwell use): ft ft in.
Water Supply Well: S 1.SCREEN
❑A Cultural FROM TO DTAMETER SLOT SIZE THICIOVESS MATERIAL
'❑Municipal/Public it ft in.
❑Geothermal(Heating/Cooling Supply) dential Water Supply(single)
❑Industdal/Commercial 17Residential'Water Supply(shared) ft ft
18.GROUT
131rdgatioxi ❑WCllS>100,000 GPD FROM To I NATMtrAL ENPLACEMENfMETHOD&AMOTW
Non-Water Supply—well- - U ft 73 ft lVeofi,
❑Monitoring ❑Recovery ft ft
Injection Well: - t�3.
❑A uiferRechar a ❑Gtouti fL ft
q g ndwaterRemediaon
OAquifer Storage and Recovery ❑S 19.SAND/GRAVELPACK rfa licablc
alulity Ba[rier FROM To I MATERIAL EMPLSCEMENr METHOD
❑Aquifer Test ❑StormwaterDrainage ft R
❑Experimental Technology ❑Subsidence Control ft ft
❑'Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Iieating/Caoling Return) ❑Other( lain under#21 Remarks) FROM To DESCRDrt•ION color,hudnem sovroek a in Sim eta
ft ft
4.Date Well(s)Completed: 3—q-Z 3 Well m# ft ft
5a.Well Location: � �rn I'rr �- et�- C ne>S S AA6 ft ft
'JoAnn Tohhsw✓ ft ft
Facility/Owner Name Facility ID#Wapplicable) ft ft ? �-, ._
N4 2-4 ��) IG- VaCo6h J�bI wv L'htrrt.l ���Il .. ft o ....P..,a
Pbysrealr naatrss,City,and Zip ft ft MAR 2 0 2023
21.REMARxs.(
county l xLsW� Pmc,'�.a�n-q UnA ParcelIdentificatioallo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Wong is sufficient) 22.Certification:N S l � 34 ' 33 ' W
s 3�7 ,Z&
.6.Is(are)the wll(s):*ermanent or ❑Temporary J 1 30 T Sigaaturb b£ eA etor Date
Bysfgningthisfornt,lhere ce
7.1s this a repair to In existing wen: ❑Yes or To 1SANCAC 02C:0100 or7 that the
02C.0200(bell Co stracdon Sr aandardr and that a copy
edin accordance with
If this is a repair,fill out latown well construction it formation and explain the nature ofthe ofthk record has been provided to the well owner.
'repair under#21 remark section or-on the back ofthls form - --
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells havingthe same You may use the back of this page to provide additional well construction info
construction,only 1 GWiW 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarla Box).You may also attach additional pages if necessary.
drilled:
a 3 0 9.Total well depth below land surface: 24.SUBMITTAL INSTRUCTIONS
(ft)
Formuhlplewellrfist all depths►fdiiftrent(example-3Q200'and2Q100) t Submit this GWl within 30 days of wen completion per the following:
10.Static water level below top of casing:_ (ft) 24a•.For All Wells: Original form to Division of Water Resources (DWR),
TJworer level is above eosin&;use"+• r�J Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter. l a Cm� 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
11-- p Program,1636 MSC,Raleigh,NC 27699-1636
12 Well-construction method:
(Le.auge,rotary,cable,dkectptab,etc.) I 24c.For Water Supply aad Ouen-Loon Geothermal Return Wells Copy to the
county envuoraaental health.deparunent of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells nrodnune over 100 000 GPD-Copy to DWJR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Ralwgh,NC 27699-1611
nn ''
yr
13b.Disinfection type: Amount:_ 2 JU. )
'Fong 7 GW-I ( b North CarolinaDcPmta=t ofEnvimnmeatal Quality-Division ofwaterResommes
Revised 6.6 2018