GW1--03948_Well Construction - GW1_20230612

WELL CONSTRUCTION itECORD(GW-1) For internal Use Only:
1.Well Contractor information:
14.WATER TONES.
FROMt 770 DESCRIPTION
Well Contractor Name :t[. ft.
3 )se-A ft. ft.
NC well Contractor Certification Number 15..OUTER CASING for multi-cxsed wells)OR LINER(Ka licable)
FROMi TO I DIAMETER I 7 .S 'M
't11CKNESATERIAL
IMF..I l 1 1'1 ft, ft.
11
Company Name
16.INNERCA$1 GORTI,BING •ewhermal close d-tou
��
2.SVell Construction Permit#: 1-K!>t� 6 7 FROit TO, DIAMETER TIi1CKNESS MATERIAL
List all applicable wr.11 construction permits fh•e.U1C.Counq•,State.Variance.etc.) ft.
3.Well Use(check well use):
�- T cj
17,SCREEN
cL
W
ater Supply Well: FROM TO MAM1ETER SLOTSIZE THICKNESS D1AIMU M.
Agricultural [3Municipal/Public ft- ft. in.
(I lcating Cooling Supply) 0 csidential Water Supply(single) ft• n• in.
Industrial/Commercial Residential Water Supply(shared)
lx,GROUT
ItTieation FROM TO MATERIAL EMIPLACEAIENTMETHOD&AMOUNT
Non-Water Supply Well: tt. Q ft. P LcV f
ft.- -ft.-
Injection .. i Recovc - --- - - - _--
_-- - ftdonitoring---- -- - - --- rY - -- --
Injection Well: ft. ff.
Aquifer Recharge Groundwater Rensediation 19.SANPlGRAVE[.PACK iif a licabte
quifer Storage and Recovery [2Salinity Barrier FROM I TO I MATERIAL EAIPL.ACF.MIEN''r M1F.TnOn
Aquifer Test [3Stonnwater Drainage OQ ft. 700 ft. o 1.I
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed IAvep) [2Trdcer 20.DRILLING LOG(attach additional sheets If necessary
FROM TO DESCRIP770N(color•hardness,wit%rock h• e, ruin tire,Nc.)
Geothermal(flea tinglCooling Return) ryry Ather(explain under 421 Remarks) ft Lk ft. W
4.Date Well //
s)Completed: 0"td� Well 1D#
ft. ft. c ti;_. °w t a aV e
5a,Well Location: R
0 n-S R6 Y" (9- 6 7­;i getj ft. ft. n n• n
Facility/Owner Name Facility ID (ifupplicable)
f6 ft. � L U L J
ft. it.
La7ua. V re��n_ Qtia& tix �JM.s1r V
Physical Address,City,and Zip
P17 `_ 21.REMARKS a-
_-�`-1
Couniv Panel Identification No.(PIN)
5b.Latitude and longitude in degrees?minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Cer'ficatioi
N-77• 1 9,7 61- W4&6;z-
6.ls(are)
the well(s) ernmanent or [37fenmporary Signature ofCcrtitied Well ttractor Date
By signing this form,1 hereby certify that the stal!(s)was(were)catstructed in accordance
7.Is this a repair to an existing well: ®Yes or �ttio with 1Sd NOIC 02C.0100 or 15A NCAC 02C.0200(tell Construction Standards and thar a
e well Darter.
lfthis is a repair,fill out known Nell c onsurtction information and explain the nature of the copy of this record has been provided to th
repair under#21 renmrks•section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Luop 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.T �-7otal well depth below land surface: /X 00 24a. For All Wells: Submit this form within 30 days of completion of well
ror•ohnhiple wells list all depths ifQ erew(erantple.3 an200'and 2@1001 construction to.the.following:
10.Static water level below top of casing: J V11' (ft.) Division of Water Resources,information Processing Unit,
1f uvicr level is above casing,rise +' 1617 M211 Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For injection 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: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground InjecKon Control Program,
FOR WATER SUPPLY WELLS ONLY: ,/� 1636 b1211 Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: %K ^ 24e.For Water Suaniv&injection"Wells: In addition to sending the form to
the addrrcss(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: C Amount: 2 completion of well construction to the county health department of the county
where constructed.
Form GW-i North Carolina Department orGnvironmenial Quality-Division of Water Resources Remised 2.22-2016