GW1--03328_Well Construction - GW1_20230516

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Well Con�tractro Nam ' FROM TO I DESCRIPTION
NC Well Contractor Certification Number -/ `1S:OUTER,gg].WG` ofniiitt4caseed'weus ORLIMR Ga II�ble
��rGl ��1 Zd�01 S ✓✓)C, FROM R. 00 ft- DIAMETER in. T..CA 4&)
Company Name
��.r Dn y� 16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: l/ FROM TO DIAMETER I TMCKNESS MATERML
List all applicable well construction permits(i e.UIC,County,State,Variance,etc-) ft. ft. in.
3.Well Use(check well use): ft. fL im
Water Supply Well: 17.SCREEN
E•ER FROM TO DIAM SLOT SIZE THICKNESS MATERIAL
Agricultural 0M icipamblic 0 fL IL in.
Geothermal(Heating/Cooling Supply) 2kesidendal Water Supply(single) g, ft.
Industrial/Commercial [3Residential Water Supply(shared) Is.GROUT
Irrigation - FROM I TO MATERIAL EMPLACEM W METHOD&AMOUNT
Non-Water Supply well: (7 fL fL ff S0 6b5
Monitoring Recovery. M ft.
Injection Well: ft. ft. oc
--Aquifer-Recharge oGroundwaterRemediation
19:SAND/GRAVEL PACK rf a llcable
Aquifer Storage and Recovery Salinity Barrier FROM To I MATERIAL. EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. R'
Experimental Technology OSubsidence Control ft:. R• t•_ ___ j
Geothermal(Closed LOOP) [3Tracer 20.DRILLING LOG attach additional sheets if necessary)
I_ Geothermal(Heating(Coolin Return) MOffier(explain under 421 Remarks) FROM I TO DESCRIPTION(color,rmrdness,soilfrocictype.grain sin,eta
ft. ft.
4.Date Well(s)Completed: . "2&'Well ID#
Sa.Well Location: ft. ft.
r'dt�gp A&"-s s^S ft. ft.
Facility/Owner Name e ,JF/acilitytlD#(if applicable) it. ft.24 ft. 4
Physical dress,City,and Zip 4 w "y Ad
D re— 4 G Z 7 Z 7 21.REMARKS- PTY I r 9592
County Parcel Identification No.(PIN)
Sh.Latitude and Iongiinde in degreeslminutedseconds or decimal degrees:
(ifwell field,one laMong is sufficient) 22.Certir tion:
31- „ M0 7 /a_. 670 6s w _
6.Is(are)the well(s) rmlment or OTemporary ign of Cemfied Tel Con Date
By signing this farm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or tom""' with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out brown well construction information and erpl do the nature of the copy of this record has been provided to the well owner.
repair under#2I remarks section or on the back of this farm.
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
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 if different(example-3(a)200'andd22@100) construction to the following:
10.Static water level below top of casing: �7 (ft.) Divlsion of Water Resources,Information Processing Unit,
If water level is above casing,use"T" 1617 Mail Service Center,Raleigh,NC 27699-1617
il.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
/ above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: .>r t�l construction to the following:
(Le.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) Method of test: Q lOtwJH 44c.For Water Sunny&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.1)6Wection type: Amount: l Brw,,a eA completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016