GW1--03334_Well Construction - GW1_20230516

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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FROM TO DEBCR�TION
Well Contractor Name ft. ft.
1515-A ft. M
NC Well Contractor Certification Number 15,OTTIIER•CA YN.G.for•inu *enaseedd well's OYt 1dNE�JR-if li Aceble F/✓I i�U V�. FROM TO D/rGr J R Nf � n`�
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Company Nalne 16.'INNER.CASING OR.TOBING- edthermal4osed-loo
2.Well Construction Permit#: sw'z2- toe)66 FROM TO DIAMETER THICIINES3 MATERIAL
ft,
tL in.List allapplicable ivell construction permits#.a.UIC,County,State,Variance,etc.)
ft. ft. �
3.Well Use(check well use):
.1 SC EN
Water Supply Well: FROM To I DIAMETER SLOT SIZEI THICiOVESS MATERIAL
Agricultural E)MunicipaMblic fL fL
Geothermal(Heating/Cooling Supply) •A17@aidential Water Supply(single) ft. ft. In
IndustriallCommercial Residential Water Supply(shared) 18..GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Irri at10n Non-Water Supply Well: IL �'4vt G
Monitoring ORecovery ft. ft.
Injection Well: ft. ft.
:.)Aquifer Recharge []Groundwater Remediation 19,SAIVDIGRAVEL PACK.ir;a 11 allle
Aquifer Storage and Recovery '1Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
? ft. ft.
Aquifer Test [3Stormwater Drainage
k• .1! ft, ft.
•t..
Experimental Technology ,�:t Subsidence Control
Geothermal(Closed Loop) Tracer -20.'DMLING LOG.attad t fidtiffib sheet:IEnecessa
FROM TO DESCRIPTION color hardness soWroek size ela
Geothermal Hestia Cooling Return Other(explain under#21 Remarks O ft. a,
4.Date Well(s)Completed: ��'2 3 Well # I it ID t
rt. ra
So Well Location:
ft. ft. r,...s.�� •. a�'
4and v t3aewbif ft. fr. k 16--o
Facility/Ow er Name Faoility ID9(if applicable)
300 VV&& 00te- TrC4 6►�Kdv;t 1,/ 1479 fL fr. AY 1 2Q23
fr. ft. t r
Physi al ddress,City,arift If
v«
i/ nn 21.REMARKS
Gf/aWe.11
County Parcel Identification No.(PIN) -
5b.Latitude and longitude In degrees/minutes/secon4s or decimal degrees:
(if well Bold,one lat/long is sufficient) 22.Certification:
35.55qG5 N -8l.11000 2
Si of Certified Well Contractor Date
6.Is(are)the well(s)SPermaneut or [3Temporary.
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: [3Yes or ffiNo with ISA NCAC 02C.0I00 or ISA NCAC 02C.0200 Well Construction Standards and that a
ifthls is a repair,Jill out known well construction information and explain the nature of the copy of this record hat been provided to the well owner.
--repair under#21 remarks section or on the back of this form. 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 I GW-1 is needed.'Indicate.TOTAL NUMBER of wells
construction details. You may also attach additional pages if necessary.
drilled: SUBMIT m INSTRUCTIONS
9.Total well depth below land surface: 605 (N 24a: For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(I dWerent(exartrple-3@200"and 2@1001 construction to the following:
10.Static water level below top of casing; (fL) Division of Water Resources,Information Processing Unit,
If water level Is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (In.) 24b.For Infection 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 me�h�o — construction to the following:
(i.e.auger,rotary,cable,directps, .
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a,Yield(gpm) Method of test: 14. v 24c.For Water Suuniv&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:C h UV n G Amount: C V S completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quafity-Division of Water Resources Revised 2.22-2016