GW1-2023-01771_Well Construction - GW1_20230223

WELL CONSTRUCTION,RECORD(GNV--1) For1nternal Usc Only: ;
1.Welt. ontractar information:
'14.WATER ZONES-:'r.
FROM .TO DESC111MON
lVit Cdn ranorNamo tt. % ft I
NC We, ontraclm,CertificationNu ber _
1 F /gt jj :15.OUTER CASING tar ma rased*ills)OR LINER if a"' ltcable
/ / � "FROM 7O DIMr£TF[t - ..T11ICK �SS h rAL
Compaay Tlame III°°° ft. .,,• in:.
; .
�/ 1'16.1N aNMCASINGORTUBINGt•eotherm close -too`
2.Welltonstrucilon.Permit#: ��' `i �' � 1� /�� FROM -TO IAMETER THICKNESS" -MATERIAL
Ustall applicable urUeanctrucadnpenitits(l.o:IAC,Counoy,Stag Narfarice,etr.J ft ft. In.
3:Well Use(checkwelluse): tt. u. In
Water Supply We11: 17.SCREFaY. mw, ti.
'FROM TO . - DIAMETER . SLOTS -TRICKNFSS ArATERIAL
QAgdctdtutal E3Munieipal7Public• L t
IIGeotheluial(ficatiBgtCooling.Silpply) residential Wafer Supply(single) ft. ft. In. V
bindustrial/Connnereial t]Residential Water Supply(5h5red) --48aGROUT:
Olrii ation I3Wells>.I00.000GPD FROM TO 'MATERUL. _ 12uPLACshn;rrr-r nontfwur4r
Ar
on-Water Supply Well: s".JJ �d ��_•=�-.---_ ���
QMonitoritig Dkecovery rt. tL 2 .
Injection Well: _
QAquifer Recharge []Groundwater Remediafion 19.SAND/GRAVEL PACK applicable)
OAquifer-Storage and Recovery OSalinity Barrier FROM .'?.IATERUL EAtpLA h oD
OAquiferTest OStormwaterDrainagc
❑Experimental Technology 0SubsideneeConti6i tt:. ft•
❑Geothemlal(Closed Loop) OTracer 20.DRILLING LOG attach additional iheettIf neeessa
QGcotliermal FROM TO '-DESCR MON color,hardy sotOrnik a n aim tic.) -
Q�catinglCooling Return), .►30ther,(explain tinder#21 Remarks)
4.Date Wcll(s),61iiplete4- Wa mil R' !L
5a:Well 1: tion':
— - - "A1A ft..
R• tt•
4,z
Fachity/0 Name Facility-IM if applicable) t., fL `
/ ft. it,
zAIAZP
Phya lAddres;City, !P r� ✓� �j� fL R. TEB 6] r
✓ / / �11.�RE11ARK5.
Coumty Parcel[dcntificalionNo.(PIN) if ii;a S3:C�1 �i'; 3W�r7(jr:f
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
ell field,one>allo g is sufficient), 22. tific
J N =W
6.,Is(are)the well ermanent or OTemporary orcertiried el nuactor ate
igni ig ildr hereby eert{fy Aai the>irll(s)was(were)consnuctr d in aecordanc`e with
7.-Is this a,repair to an existing hell:. OYes or No "5A NCA .0109 or I5ANC4C 01C.030011'ell Construction Standards and that a copy
Jfthis Lr a repair,.fiit out knoom ivell eonstructiort fl fotntotiorr6r 1 crplaln the nature ofthe ofAis record has been provided to the rrll miner
repair under*21 rcmarkr section aron the back ofthisfornt. 23.Site dingrnm'or additional well details:
8:,For Geoprobe/DFT or Clased-Loop Geothermal Wells having the sarne You may use the back of this page to provide additional well,construction info,
constmction,only.I G�i'-I is needed. Indicate TOTAI.NUAfHER'of wells (add�Sce Over'_in Remarks Box).You riiay,also attach additional pages if necessary.
drilled:-
,+ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land suditm.Fo Submit this GW l Within 30 days of oven completion per the following:
Yr m'altlpla rve&Os1 ail depths f different(exanjple-3@200'and 1@100�,
10.Staticovater level below top of casing:. �' (R•) 24a. For All.Wells: 'Originail forin:to Division of Water Resources (DWR),
ifiiaterlevclLsaboperns{n&use l Tutors:ts+tion,Proceising Unit,1617,3�SSC,'Raleigh,NC27699-1617
11:Borehole diameter• - // z-• (;n,) 24b.For Injection Wells:Copy to D,WR,Underground Injection Control(TUC)'
Program,.1636,MSC,-Raleigh;NC2 7699-1 63 6
12.Well constttiction method: 24c.For Water Su iv and O en-Loo Geothermal Return Wells:Copy to the
(;,e.auger,rotary,cable,cSiiettpush etc.) county environmental health department of the county where installed
• � I
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Weiss producing tint>r 100'000 GPD,Copy to DIM CCPCUA
yQ Permit Program,161 TMSC,Raleigh,NC 276994611
13a.Yield(gpm) Method of test:,< f(9
13WDlsinfection type, _ Amount: -. .�
Fusin G1v-1 North Carolina Department of Environmental Quality-Division of Water Resources; Revised f>6 2018 '
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