GW1--04135_Well Construction - GW1_20230623

. I -..-
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Informati D• 1 ,
1:1)(- 1.1.010fl
C(akO(-' 14,WATER ZONES
Well Contractor llama
FROM TO DESCRIPTION . ..
N� 61 /p n. G o ft. ; 1 11 -
NC 1'ell Contractor Certification Number /r� f6 a�5 !i.
Well
11 /' +i 15,OUTER CASING(for multi-cased wells)OR LINER(ifap licable)
p51 /� l 1 y l l I_J' 1 I I1 to- FROM TO DIAMETER THICKNESS MATERIAL
rr {�W C�I^1\1 �/�/s=-1 111 f/ ft. /$Q rt. 1.t In. 1 fv(.
Company Name 16,INNER C 1NG OR TURING(geothermal closed-loop)
2.Well Construction Permit p: 3f' 76 9P9 400-76 FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(Le.VIC.Country.State.Variance.etc.) ft. fL la.
3.Well Use(check well use): ft. ft. In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZETHICKNESS MATERIAL
gricuitural 0M cipaUPublic /90 n 033ft. . q in. ,(916 014° PVC
DGcothcrmal(Heating/Cooling Supply) Efcsidential Water Supply(single) • ft. it. In. -
aIn us t ria I/Co mni c re i a 1 [Residential Water Supply(shared) .10.GROUT
tngation .1, FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft. It. /Y 61faf "Pimp
13monitaring — ---- °Recovery -- -ft-.-- - -ft: -, "Pimp
— -_
Injection Well: R. rt.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0Saliniry Barrier FROMro MATERIAL E�fPLACE1fENTMEIITOD
Aquifer Test DStarmwater Drainage I R RI.0 S ft. 4 ( (), Gr K{✓I
•
Experimental TechnologySubsidence Control ft. It.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary) .
°Geothermal(Heating/Cooling Return) f Other(explain under 1/21 Remarks) FRONT To DFSCRIPTIO\(color,bardoets solVroek type,grain size,etc.)
G m 6 ft. lid
_- b
4.Date Wells)Completed:•-(e7.' " 3 Well IDII 6 Q fL /80 n• eli-z- t!
Sa eALocation; IUO.ft. 3 fL l.5'
0 .esh -:r 8. clad' ft' (�hi e
FecilitylOwnerName - Faeil'ty IDX(if applicable) • R• fL - ''''' e _e��.� l•1
/9g/ -,i/e) / Ai Oreemi l e ice a-7515 R. ft. JUN IV 2, r LU�
^ n
Physical AddressCity,and Zip .
f�, ,-(— 21.REMARKS - _-.9 t)t.- .
•
County Parcel Identification No.(PIN) • 17,Wi11 SO;C^
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/lang is sufficient) 22.Ce adon: •
• N `� i�v -u- 6�-7-
6.Is(ard the well(s) Permanent or °Temporary • Simone o rt red Well ontractor Date
By signing tilt font,. tify•I hereby cer that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing weII: Yes or r'o with 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this it a repair,fill out!mown 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:
8.For Geoprobc/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.
drille9.Total
ot C 3/ . SUBMITTAL INSTRUCTIONS
Total well depth below land surface: (R.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths If-different(crumple-3@200'and 213100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+'• 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:• .'(i) 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: construction to the following: .
(i.e.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: 24a For Water Supply&InlectionI 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: completion of well construction to I the county health department of the county
- where constructed.
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016