GW1-2023-02815_Well Construction - GW1_20230417

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only-
I.Well Contractor Information:
Fxo—m DESCRIPTION
Well Contractor Name ft. ft.
L�S it. ft.
I
NC Well Contractor Certification Number 15.OUTER QASING for umnpcaswdwells ORLWER cable
FROM TO DIAMETER THICIQtESS MATERIAL
p rw �6 ((,o c
Company Name 16 INNER C14RING OR TUBING 'eothermai clamed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft ft. in.
List all applicable well construction permits(i.e. UIC,County,State, Variance,etc)
ft. ! ft. [a
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SITE TMCKNESS MATERIAL.
lGeothermal
ultural C]Municipalftblic ft l.8 ft L 1° 10j 0 40 ✓C,
ermal(Heating/Cooling Supply) Residential Water Supply(single) ff ft. in.
trial/Commercial Residential Water Supply(shared) 18.GROUT,
non FROM [I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ater Supply Well: (� tt ft bhk��` 1�1✓�
toring Recovery ft. j ft.
n Well: ft ft -- --
er Recharge Groundwater Remediation 19.SAND/GRAVEL PA (if a Ifeatite
er Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
fer Test �StormwaterDrainage -� . to ft-
ft
rimental Technology Subsidence Control ft. ft.
hermal(Closed Loop) OTracer 20.D GLOG additldtlatshutd'if.21=w
FROM TO DESCRIPTION color hardues%sonhock in sUA etc•
hermal(Heatin Conlin Return) Other(explain under#21 Remarks) ft. (q ft l o P d 1
4.Date Well(s)Completed: Well II)#
ft ft.
5a.Well Location:
ft. ft
--
Facility/Owner Name T— Facility ID#(if applicable)
ft ft. APR 1 7 2 0 230
----�--� fL ft
Physical Address,City,and Zip
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
(if well field,one latilong is sufficient) 22.Certifichtion:
N —77 ,1 j y W
i
6.Is(are)the weil(s)OPermanent or emporiuT
�f�patmCertified V&AA 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: [3Yes or [3No with 15A NCAC 02C.0100 or I5A NCAC 02C_0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this r1cord has been provided to the well owner.
repair under#21 remarks section or on the hack of this form. 23.Site di am or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may Oe the back of this page to provide,additional well site details or well
consnuctio details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells �
drilled: SUBMIT'li INSTRUCTIONS
9.Total well depth below land surface: 1. 0 (ft-) 24a24a. 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� constructiop to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" ! 1617 Mail Service'Center,Raleigh,NC 27699-1617
C[ i
11.Borehole diameter: V (in.) 246.For i�iection Wells: In addition to sending the form to the address in 24a
C" �/ above,alsl submit one copy of this form within 30 days of completion of well
12.Well construction method: constntctio to the following:
(i.e.auger,rotary,cable,direct push.etc.)
Divisio¢of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: ! 1636 Marl Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) Method of test: 24c.For Water 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
13b.Disinfection type: Amount completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-i ivision of Water Resources Revised 2-22-2016