GW1-2023-02727_Well Construction - GW1_20230411

WELL CONSTRUCTION RECORD(GY-All For Internal Use Only: M
1,Well Contractor Iafat'mation:
14.WATER ZONES t
FRO31 TO DESCR1PT10Y '
ti{►cOCoaaactorNsme R. -7 f6 S
fb p,
NC Well Caatmclar,CetlificationNumber I&OUTER CASING for tnuld-eased'wells OR LINER(Ira tlt able),
TU
FROM • Drna1>;- B
IZK THICICKE
(�?eL t l�c.�m 1 ,L n
t
CompanyNantr 16.INNER CASING OR MING eotbermalclosed-too I
FRO\S TO DIA11iEM TSICIGIESS AfATERiAI•
2.WeU Construction Permitt ?J59o2a' 10O1d�� IL 1L ln.
Llrt all appticableurll comavctfon pelts to.a.UIG County•Wate,Variance,ela) Iw
n R
3.Well Use(check well use): t7.SCREEN
Water Supply well: FRoat TO DIA.jjt1:rER SLOT SUZ TtnCKM5 1HAT.F AL
❑A culttual ❑Muni ' blic R - (<- ,r In.
❑Geothermal(Heating/Cooling Supply) fflfesidential Water Supply(single) R, to la
-❑Industrial/Commercial ❑Residential Water Supply(shared) se.GROtrr
❑Irri an ❑WeII s>IOOOOOGPD FROM TO a1nr1'RIAt. L&IF ACC1�`nhttflnOD&nafOt>vt
Non-Water Supply Well: - -- - --- - - - - - - - - -- - --
- - - OMonitoring- -- ORccovery R rL
-Injection-Well.,i M R-
(7Aquifer.R&bfte =, ❑Groundwater Remediation ]9.SAND/GRAVEL PACK r a ucabie
OAquifcr Storii&andRecovery OSaliaity Barrier FROM To aunt R1l+I �m�CEtit>rn METHOD
OAquifer Test `
❑StormwaterDrainage n ft. 1-- �'
OBxperimentalTechnology OSubsidence Control n- n'
❑t,00thwmal,(Closed Loop) l7Ttacer 20.DRILLING LOG attach eddldoael sheets U aeeeua
FROM TO DFSCRIP7IOH color hardy sotproek Sot Ur:
pGeotheimal(13eatia Cooling Aenua) 170ther(explain under{i21 Remarits) ! IZ R /
R f1.
4.Date Well(s)Completed:
h 1G
Sa,Weil Location:+r
_ bl
c��ns4+�i� 13�.��\
i - - ft
Facili ty/OwnerNaie Faeilit IDI(if applicable) 1t.
• •_ 11 L=n his� •Col h P �fly Sfnih '�h lV•� rr. t►. 1 ! 2023
Physical Address,City,and Zip ` r / fL R' °` - .. :} 1. r•• °
2I.REMARKS _
CLyah, 1 Parcel IdeatificationNo.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifweli field,one laub g is sufficient) 22.Ce cation:
' 3s,C619 N "77.161 QS1 W _,J 16���_ 22
' Signature o Cerfied ti WellCotutactor Date
6.Is(are)the r CU(s): ermanent or OTemporary
Rom' Bysfgnfng thtr farm,I/rerebv crrtlfv that the>,+eff(s)xas(ireroJ constraCled fn accordance with
i 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and riot a copy
7.Is S)ils a repair to an etilsting well: ❑Yes or of this record liar been provlded ro the weft owner,
ljllris 60 repair fd1 our blown we11 Can5tnredcn f rarnralfon and Miain the nalure of file
-pair under#21 frmarkasectton or an the backofthfsfamL 23.Site diagram or additional well details:
ff.
-8.For dioprohe/DltT dr•Closed-"op Geothermal Wells having the same You may use the back of this,page to provide additional well construction info
cousttuctibn,only I GVK-1 is needed Indicate TOTALNUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: ,� 24.SUBMITTAL INSTRUCTIONS
9.Tgto]"pU dgpth heiow land surface: 7- 6 (O Submit this'GW-1 within 30 days of well completion per the fallowing:
For utopia eNs fist ali depdv.(f d ffererrt(example-3©200'and 2@1001. ,
I' ' 1 , (�) 24a. For All Wells: Original form to Division of Water Resources (DWR),
16.Static water level below top of casing:„ t Infortnation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifimler level h above caring.use.4.
(^ 24b.For In]ecdon Wells:Copy to DWR,Underground Injection Control(IIIC)
11.Borehole d�umeter: v (in.) Program,I636 MSC,Raleigh,NC 27699-1636 -
12.Well const ctioa method: �V'- l�oT uS 24c.For Water Supply and O en-Lbo Geotbermtil Return Wells:Copy to the
(iC.auger,rotary I cable,direct pusb,cm) countyenvuattmea deplartrarnt of the county whew installed
EWATEOUPPLY WELLS ONLY: 24d.For Water Wells rodticln over 100 0110 CPD:Copy toDWR,CCPCUA,
Pertmt Program,I61 I MSC,Ratctgh,NC 27699-161 l
10 Method of test:
type:�` Amount:
Farm GW-1 Nonb Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6-2019