GW1--04136_Well Construction - GW1_20230623

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: /� .
/leis 2 Gc AVC1ey -id,WATERZONES ' . . ,, -
FROM TO DESCRIPTION
Well Contractor Name �b ft. `-'76 ft. rn eA G.1,6)e.
„�,Q,,^cA
3 I�V w 4 ft. !! ft. ••77�1`r''++..�ryt
NC Well Contractor Certification Number -IS.OUTER CASING(for multi-cased wells)OR LINER(it op licable)
ry i /� ti �a i {ry FROM TO DIAMETER TIIICKNESS MATERIAL
W T-f�T'' I��( W`a+t 1 v) / R. C'y ft. in.
Company Name / 16.INNER CASINGOR TURING(geothermal closed-loop)
2.Well Construction Permit Y• f t1S1 4 `.` J 00 6 ct7 FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e,UIC,County.State.Variance.de) ft. ft. in.
3.Well Use(check well use): i-o-v 31 1 !t• fL In.
'17.SCREEN 'x!
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public �q ft. 7(9 ft. ^ in. / w0 {a ��
DGeothemtal(HcatingiCooling Supply) tcsidential Water Supply(single) CQ ft. VV It. G`in. 6 i! 1 `"
0industriallCommercial DResidential Water Supply(shared) 18.GROUT
m.lrrtgation trim TOT)1 MATERIAL EMPLACEMENT� METHOD&AMOUNT
Non-Water Supply Well: ft. c90 ri, p"� i �✓V r
- - Monitoring - DRecovcry -- - ft.- ft. - -- _-
Injection Well: rt, ft.
'Aquifer Recharge DGrottndwater Remediation
19.SAND/GRAVEL PACK(if applicable)
III Aquifer Storage and Recovery QSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
(Aquifer Test DStonnwater Drainage p7® ft. '' ft. .k. t:7.,, Pik V r
Si Experimental Technology DSubsidence Control ft. ft.
Geothennal(Closed Loop) ElTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness toll/rock tcpe,cram site.etet
ill
Geothermal(Heating/Cooling Return) f Ottter(explain under d2l Remarks) 1 ft. ft. rY%l.X�6 rR# 1 S 1}e_ 1 5
4.Date Well(s)Completed: U" /(
1 V`C DM
i-� Well ft. ft. d
ft.Sa.Weir Location: ft. 4`Yt r�-'rt^ :fib '
U n3 RPOZA Q & j • • ft. . _
Facility/Owner Name ' Facility 1D0(if applicable) n. ft. <`1 i n r n2
n pp 11 ft. rt. J U w ,; ')
trisun
•
Physical Address,City,and Zip n. rt. lU(�_ <„i^ t ?C:. ;; I I
21.REDiARK� ii i N4.;,t: 3,-
P E.e i.f. —milliee
e
County ParcelldentifcstionNo.(PIN) sj .
Sh,Latitude and longitude in degreesiminutes/seconds or decimal degrees:
(if well field,one►al/long is sufficient) 22.Cer'Beano :
6.Is(are)the well(s) er ianent or OTemporary
Signature of Certified ell tractor Date
By signing this form,I hereby err*that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or ®t"Co— with iSA NC4C 02C.0100 or iSA NCAC 02C.02011 Well Construction Standards and that a
If this is a repair,Jill our known well construction information and explain the notate of the copy of this record has been provided to the well owner.
repair under 1i21 remarks section or on the hack if 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 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
--7
9.Total well depth below land surface: /rt" (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().100'i construction to the-following:
10.Static water level below top of casing: I a., (ft.) Division of Water Resources,Information Processing Unit,
Ifwster level is above easing.use"+' 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: V (in.) 24b.For infection Wells: In addition to sending the form to the address in 24a
�4 above,also submit one copy of this form within 30 days of completion of well
12.11'cll construction method: 1 construction'to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY!YELLS ONLY: �+ 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(pm) /0 Method of test: �V 24c.For Water Supply Sr 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\INkt t Amount: 3 C7 Z completion of well construction-to the county health department of the county
where constructed,
Form OW-I Noah Carolina Department of Environmental Quality-Division or Water Resources Revised 2-22-2016'