GW1-2023-02723_Well Construction - GW1_20230411

WELL 4tONSTRUCTION RECORD GW-1 For Internal Use Only:
I.Well Contractor Information:
e- 74.WATER ZONES
i
FROM TO DESCRIPTION
Wall Contractor Name , fG l fG
3 �? fG �.
NCB'ell Coatrector CerdficationNumber IS.OITiER CASING for could cased wel OR LINER f o ll,tb
(�1E� hey G�Je.1,� �v 1' FRoy ro is TxlcicvPss
w� L
Company Name 16.WNER CASING OR TUBING eothermal dosed-too i
�rJ�S;X�aa't 6Ra FROM To RML
2.Well Cons"tion Permit#: e. fG ta.
List atl applicable such tonstructton permits(La.UIC,Count';•SYote,Variance,etc)
fG R [a
3:Well Use(checkwell ase}: 17.SEEN
Water Supply Well: FROM TO DIAMETER sLor SIZE Tmcxivess MATERIAL
DAgricuitural ❑MunicipallPublic fL 71 ft' ln. L! OVC
❑Geothermal(HeatinSICooling Supply) I ential Water Supply(single) R fL rT ia.
'Eiladustrial/Couftmereial ❑Residential Water Supply(shared) IS.GROUT
plrri don ❑Vi►e11s>100000GPD FROM TO a1ATxRrAL EnIPLAcvra�rxoD�aHou.�rt
n 0 1c t�v
Non-water Supply WeU: —- -- -:- - - -
❑Monitoring ❑Recovery m tt.
7Injeetton•Welt:1 ft. ft.
ClA uifer-kecheige ;- ❑GmuadwaterRemediadon
4 - I9.3ANDIGRAVEL PACK ifii liarble
Y 'i" OSalini Barrier FROM TO MATEMAL MPLACr+vn;nn atsrxaD
❑Aquifer Storage anti Recovery ty
❑Aquifer Test ❑Stormwater Drainage �Q R' 7
•❑Experimgatal•-Teclptology ❑Subsidence Control
t 20.DRILLING LOG attach additional shtets•tf uectss
❑Geothertnal;(Qlosed Loop) ❑Tracer
FROMI TO DFSCRiPr70N color hardy solVroeic 4. �d
❑Geothermal.(Heatiog/Cooling'Itetam ❑Other(explain under#21Romer, ft- t 1 is fry hit
4.Date Well(s)i�ompleted:.LLl� WeU ID# ft. 1
So.WeU Location: T
(-- • Facility/OwnerNeme Facilityll)#(ifapplicable) to
c.,et �` '� AP 1 1
� � -'2022
-
plrysicolAtidress,City,ecd Zip - _
21.REhL4RKs s s�r
�•.)::..
,County, Parcel Identification No.(PIN)
�^•,• � .
i 56.Latitude and longitude in degreedminutes/seconds or decimal degrees:
�•' (if�vell field;one!at/ioag is sufficient) 22.Ce cation:
.13 N /61 5el w.
Signature:of Certified Well Contractor Date
6.Is(are)4beev'ell(s): Per�saent .or. ❑Temporary '
1)vsigning this form,lhereby certify that the tvell(s)was(xwxe)constructed in accordance pith
7.Is,this a repair to an.exlsting will:.; 13Yes oe MNo 15AHCAC 01C.0100 or 15A NCAC 01C.0100 Ireli Construcdon Standards and that a copy�, -^ Ifthlr is a repatr;� 11 out.btotcn:well,cgnstrvctlon hrfarmation and erplafn the nature of the ardzlr record has been provided to the rued inmer.
` repair tinder#21 aria section or on•ihe back ofthts fornr 23.Site diagram or additional well details:
You may use the back of this page to provide additional well Construction info
&Foe'Geoprobell)PT 6-66'sed-Loop Geothermal Wells having the same
It%Y cotistructioa;only I OW]is nettilixi. indicate TOTAL NUMBER of wells (add'See Over'is Remarks Box).You mayalso attach additional pages if necessary.
drilled: `" / 24.SUBMITTAL INSTRUCTIONS
9.T tal well;d••ptH;below land surface..
�r (!t) Submit thtsf GW 1 within 30 days of well completion per the following:
Forrr�ulKplewehs•hsaalldppths,Ifdjfma(exomple-3@200 and2@109).
_ I• .' . ere1� 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Statiewatq-1pirel,below top 9f casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-16I7
Jfuoterlevelis g ove.castag;cue"+"
ameter.ti • (ia.} 24b.For Infection Welts:Copy to DWR,Underground lajectibn
11.Borehole Control(IUC)
• r Program,1636 MSC,Raleigh,NC 27699-1636
12.Well-coustl uction method: Mj 24c.For Water Su 1 and Open-Lbop Geothermal.Return Wells:Copy to the
(Le.auger.rotaxx,cable,direst push,etc.) county environmentahealth.department of the county where costa
lled
FUR�WATEg1SUPPLY WELLS ONLY: q 24d.For Water Wells producingover 100 000 GPD:Copy to DWR,CCPCUA.
13ti.Yield(gym) 1O Method of test: JAI C Permit Ptogcam'1611 MSC,Raleigh, C 27 99- 6L 1
i
3 2
13b.Disinfeetlon type: C `t Amount; -
Form GW1 North Carolina Depattment of Environmental Quality•Division of Water Resources Revised G6-2018