GW1--04065_Well Construction - GW1_20230622

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information: / /
--(4i;�/./J f-ACL.yei�4c -42`l 14.WATER ZONES. •. • . .. •
Well Contractor Name FROM TO DESCRIPTION
s� / ft. ft. 72 C� oC,m)
_L a/ 9- ft. ft - ,,rl
NC Well Contractor Certification Number in . ) )
p�,� y� 15.OUTER.CASING:(fo"r m tt-easedwells: LINER(if aplicable)
'A �/' //� J FROM TO DIAMETER THICKNESS MATERIAL
/ [rGc l�xif t �J 2 rL ft. / in. 5- P 1)
Company Name Ca
y��(/�� 16.INNER CASING.ORTUBING,(�eothermal closed-loop)" •
2.Well Construction PernutV: d.23 00 00.1 3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft, ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: •
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
®Agricultural OM eipal/Public 0 ft. ft. in.
11 Geothermal(Heating/Cooling Supply) Bgesidential Water Supply(single) ft. ft. in. .
®i Industrial/Commercial LJ_.Residential Water Supply(shared) 18.GRO.UT .
1 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: t ft. ,Ya_ ' f !c .. C/ r7 �
*Monitoring 0Recovery ft. ft. �P S /�
Injectiongli:„...,
f., 4IV.
1f: ft.*Aquifer Inds/L.sI1-
,,QGroundwaterRemediation 19.:SAND/GRAVEL:PACK(if applicable):..
•
*Aquifer Storageiagd Rec vetSO 23 EjSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Ili Aquifer Test JJ y u L 0IStormwater Drainage ft. ft.
IN Experimental Te log e:; ;f..4 ijrinSubsidence Control ft. ft.
®Geothe*igtszikpzooG DTracer 20.DRILLING LOG(attach additional sheets if necessary)
•
III Geothermal(Heating/Cooling Return) I J Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
d ft. ft.
4.Date Wc11(s)Completed: Y-ZD-- 3 Well Kw s' ft- �. , ft. i� /I
5a.Well Location:
�//� �� ft. / ft. tus& /q pn,x 0_0,
�/�LrC P� t //T6'e S 7 ft. C� ft.Y r� ���`.•"I--me,_.
Facility/Owner Name Facility ID#(if applicable) ft. z7 ft.
1L/E� y
�q ` /�c�
d/ri3 G .Sd 4[��/ - ft ft.
<pcJrL r J
Physical Address,City,and Zip ft ft.
4/ 7'r0k-'e- 21.REMARKS:
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lstt/llong is sufficient) 22.Certification:
•
9 '// /v :, ,gN 947.3iY, 75 w
6.Is(are)the wells) ermanent or Temporary Sign re o em� en C ctor Date 3
signing this form,I hereby certi.6,that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes oro with 1SANCAC 02C.0100 or 15A 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 record has 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:
You may use the back of this page to provide additional well site details or well
8.For Gcoprobe/DPT or Closed-Loop Geothermal Wells having the same
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: 75- (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@200'and 2@I00) construction to the following:
10.Static water level below top of casing: -Vv (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+'•
f 1617 Mail 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
12.Well construction method above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary, construction to the following:
' g cable,direct push,etc.) g
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
e 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 7 Method of test: Cf�_ 24c.For Water Supply&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: Amount: el.g a2-c 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