GW1-2023-02812_Well Construction - GW1_20230417

WELL,CONSTRUCTION RECORD(GA-11 For Internal Use Only:
1.Well Contractor Information:
U✓fi/`" 114-c 4 y 14
U WAFER NES
FROMTO DESCRIPITON
Well Contractor Name ft ft.
NC Well Contractor Certification Number 15.OUTER LINER a ' cable
/ ! FROM TO DIAMETER THICKNESS MATERIAL
�15y c7t/rrG �ia l(i:^� D tt. R• 'L/, ln. L4 0 PVC
Company Name 16 INNER CASWG OR TUBINGfgm"w" thermal dosed-loo
FROM TO .DIAMETER TlHCKNFSS MATERIAL
2.Well Construction Permit#: fL ft. In.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)
ft ft in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTS THICKNESS MATERIAL
Agricultural �Municipal/Public ft p ft L iD ,t1(U t(C? vG
Geothcrmal(Heating/Cooling Supply) [IResidendal Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT `
FROh1 TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Ini ation ft. ft.
Non-Water Supply Well: !/ I �oryA+;Z
Monitoring Recovery ft
Injection Well: ft ft
Aquifer Recharge �Grotmdwater Remediation 19.SAND/GRAVEL PACK a ilethle
Aquifer Storage and Recovery Salinity Barrier FROM I TO MATEIH L EMPLACEMENT METHOD
Aquifer Test
[3Stormwater Drainage ft. a ft 5�,v ildte
ft
Experimental Technology oSubsidence Control ft.
Tracer 20.DRUI:IiNGLOG a di6ontikslieetsff-ueeesse
- Geothermal(Closed Loop) FROM TO DESCRH'7ION cobr aaiVrock erne.etc.)
Geothermal(Heating/Cooling Retum) rl Other(explain under#21 Remarks) ft. ( ft
3 Z� t✓� I t t '-�
4.Date Well(s)Completed: Well II)# '- ft D f
� A
fL ft.
5a.Well Location:
(!'{'tl�� ft. <v' i..-...�1•, .,a-_..,
Facility/(honer Name (�^an`r>uj Facility ID#(if applicable)
>t. ft APR 1 7 Z023
ft ft
P ysical Address,City,and Zip
County Parcel Identification No.(PIN)
i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wcU field,one 4 3 latfionng �7 7g is sufficient) 22.Certification:
I c-7 7 N — . 1 W, � __1K,'-
cure of Qertifie Co for Date
6.Is(are)the well(s)oPermanent or BfernporM
By signing thl' form;I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or f�Jl•V with I5A PIC,C 01C..0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
if this is a repair,fill out brown well construction information and=plain the nature of the copy of this r cord has been provided to the well owner.
repair under#11 remarks section or on the back of this form. 23.Site di am or additional well details:
You may tiu,e the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
const uctio details. You may also attach additional pages if necessary.
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells
drilled: to SUBMIT'IIIAL INSTRUCTIONS
9.Total well depth below land surface: (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdifferent(example-3 t@200'and 2(Qa 100) constructilision
o the following:
10.Static water level below top of casing: (ft.) of Water Resources,Information Processing Unit,
Ijwater level is above casing,use" i 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: (in.) 241h.For Yi6iectlon Wells: in addition to sending the form to the address in 24a
above,ale submit one copy of this form within 30 days of completion of well
12.Well construction method: � constructio#to the following:
(i.e.auger,rotary,cable,direct push,etc.)
DiAsioit of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: i 1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) Method of test: 24c.For`1V--ter Supply&In ection Wells: In addition to sending the form to
the addres (es) above, also submit one copy of this form within 30 days of
136.Disinfection type: Amount completion, of well construction to the county health department of the county
where comdtructed.
I
Form GW-I North Carolina Department of Envirotunental Quality- ivision of Water Resources Revised 2-22-2016