GW1--03859_Well Construction - GW1_20230609

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Con ctor Information:
Pil(, -�L'✓✓ 14:-WAT R. NES
FROM TO DESCRIPTION
Well Contractor NamQ fr, ft.
4�'4 -A ft.
NC Wall rjatmctorCortif3cation Numbor 15, UFFR•C ' .G.#or•in teased ivelCv Olt• INER'ifms cable
' PROM TO DIAMETER T81C[S3'IFSS MATERIAL
L S W Gl.}Yl • 0, i C. ft. 6 ft. "1�s"In. S R�.I ��1/G
Company Nama / C ' ICAG Q ' t9; edtherm o gSed-loop)
`S �r/ b (f+ PROM TO DL(METER THICKNESS MATERIAL
2.Well Construction Permit#: J �"" 74 ( {t, {t, �
List all applicable well consfruction permlfs As.WC,County,State,Variance,sic.)
) � g & ft. in.
3.Well Use(check well use
Water Supply Well: FROM To DIAMETER sLOTSUM THiCKNEas MATERIAL
Agricultural rRq..
cipaUPhblic Geothermal(Heating/Cooling Supply) entinl Water Supply(single) fr, ft. im
Industrial(Commercial ential Water Supply(shared) 19Ig
.G UT
MA EMPLACEMENT METHOD&AMOUNThri atioR ,on-Water Supply Well: ft. t'It { ILLl Recovery ft.
Injection Well: ft.
Aquifer Recharge [30roundwater Romediation 'YEL FA. IC(1f•a Ila leAquifer Storage and Recovery 1 E)Salinity Barrier TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3StormwaterDrainage
Experimental-Technology ( [3Subsidence ControlGeothermal(Closed Loop) OTraeer N OG. tta* i1. tionalaheet:if uecessTO DESCRIPTION color hardneaa ooWrack elze etc
Geothermal Heatin Coolie Return Other(explain under#21 Remarks /9/ ft. ►�
4.Date Well(s)Completed: , Well ID#_ ft. J ft )t t✓
ft. ft.
5a.Well Location: 1'°
D Yd eV rL fr.
Facility/Ownor Name Facility IDII(ifapplioable) I e
l a f 1 q ft. fr.
ft. ft. Q•r1 Aft::: �
Physical Address,City,and Zip
Zf.REMARKS
MZ D101,Je11
County Parcel IdontiScation No,(PIN)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if wall field,one iat/long Is sufficient) 22.Certifleation:
, ` signa of Certified W4 Contractor Data
6.Is(are)the weli(s) ermanent o` turer [3Temporary.
By signing this form,1 hereby cert(fy that the well(V was(were)constructed In accordance
7.is this a repair to an existing well: [3Yes or JgNo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that o
(/•this is a repair,fill out known well construction Irifortnaifon and explain the nature of the copy ojlh[t record has been provided to the avail owner.
repair under#21 remarks section or on the back of ihls joint. 23.Site diagram or additional well details:
8.For Geogrobe/DPT or Closed-I�oojl;Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary,
construction,only i GW-1 is needed,•Indicato TOTAL NUMBER of wells
drilled: _;-_ 3MITT I•i1VSTRUCTIONS
9.Total well depth below land surface: (ft-) 24a; )?or All Wells: Submit this form within 30 days of completion of well
For multiple wefts list all depths(fd(/jerent(exattrple-3 200"and 2@100) construction to the following;
10.Static water level below top of casing; v (ft.) Division of Water Resources,Information Processing Unit,
If water level Is above caring,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole dlamEtbr: (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 method.. V- G i a-Y/,/ construction to the following: I ,
(Le,auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)- b0 Metbod of test: GZ./✓'_ 24c.F,Qr Water Suanly &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: Cf11�1^l f t ei Amount: r completion of well construction to the county health department of the county
where conshucted.
Form OW- North Carolina Department ofEnviron nantal Quality-Division of Water Resources Revised 2.22.2016
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