GW1-2023-02505_Well Construction - GW1_20230406

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
L`f G 5C1i7�C��s Uh 14.WATER ZONES
Well Contractor Name FROM ft.
ft DESCRIPTION
//T� ft. ft,
J ,
NC Well Contractor Certification Number /� I&OUTER CASING for multi-cased wells OR LINER if applicable)
Sg�d Q rhN ` 1 J n / r 1, t't FROM TO DIAM T'R THICKNESS MATERIAL
d.�lJ V W Cr hJ I ,] ft. 0 fL � � - in. 1
Company Name t/
wllelb
3616 (]�� / 16.INNER CASING OR TUBING eothermal cl -loo
2.Well Construction Permit#: i FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc) ft ft. in.
3.Well Use(check well use): fL ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural gZe.sidemial
cil/Public Dzn ft. ft. in.
Geothermal(Heating/Cooling Supply) Water Supply(single) IL
D
IndustriallCommercial Residential Water Supply(shared)
18.GROUT _
irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: it IL 1 ) ( py
lcj.,f
Monitoring 13Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Dsalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. fL
Experimental Technology Subsidence Control
Geothermal(Closed Loop) []Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)Other(explain under#21 Remarks) C) ft� ,,,�It.. c.a �(c�
f4I A,
4.Date Well(s)Completed: Well 1D# ft' ft.
5a.Well Location: ft. ftlS� %./
mart)e� ft. fL
Facility Facility ID#(if applicable) ft. ft. APR p
ft. ft. f li i\
Physical Address,City,and Zip ft. ft
A oy 6,5
C)� 21.REMARKS
County C J Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or dedmal degrees:
(ifwell field,one lat/lon is sufficient) 22.Certification:
6.Is(are)the well(s) ermanent or ❑1-emporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Q Yes or s/ with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
Iy this is a repair•fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 1=21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled' SUBMITTAL INSTRUCTIONS
i
9.Total well depth below land surface: 5_ 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following'
10.Static water level below top of casing: 00 Division of Water Resources,Information Processing Unit,
If water level is above casing,use•'+'. 1617 Mail Service Center,Raleigh,NC 27699-1617
ii g
11.Borehole diameter: (ia.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
�H f�J J above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: / 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) o Method of test: / r I 24c.For Water Supply& Injection Wells: in addition to sending the form to
/ r the address(es) above, also submit one copy of this form within 30 days of
Y
13b.Disinfection type: Amount: V , �_ completion of well construction to the county health department of the county