GW1--04137_Well Construction - GW1_20230623

1, ,.
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: .
We-
GC G-t1f'�l4ne '44.WATER ZONESFROM TO- DESCRIPTION
R"eUContradt�.or Name' /f/y� {ft. ,ss H. �A 1 TALI s Abla
t.J �J /'° .? fl. fL �U v /
• NC Welt Contractor Certification Number ti5.OUTER CASING:(toe uwill-crised w lls);OR,IJNER.(if tip'licable) .,. . - '
,�.1�, (kid(
��,,, ( FROM TO . DIAMETER'. THICKNESS 51TERIA[.
,� ` 1 v r y tA/ -1� '�' c:=.,--)levi ' fL :4.1..c rt. X. ,n. �'40 �c.
Company Name �jq 16.INN ER.CASlNG'01t TUBING(gebttiernial eloseil-loop) `�
2.Well Construction Permit#:- i -'S�/-�-, /C b n i FROM TO DIAMETER THICKNESS MATERIAL
List all applicahlr well construction permits(i.e.UK'.County,State.t'a lance,etc.)
f6 rt. lit
an.
3.Well Use(check well use): ir`CR 3'7 ft: ft.
17::SCREEN,• „;'„ r , . „ .
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 4fgft. ft. 'a in' /lit it J° .(
r Geothermal(Heating/Cooling Supply) esidential Water Supply.(single) ft. it. In. _f
II IndustriallConunereial Residential Water Supply(shared) ts.GROUT_: _. = ,-i " ,
- -'Irrigation FROM TO MATERIAL EMPL1CLMENTMETHOD&AMOUNT
Non-Water Supply Well: I ft. ft. Vet
POVe _
_ 1
_( Monitoring . ciRecovcry. H. ft.
Injection Well: ft. fL - ----- -- -. -
$Aquifer Recharge . i Groundwater Remediation
'.19..SANDiGItAV ELPACK'(If applicable)'•`'- '
*'Aquifer Storage and,Recovcry .Salinity Barrier FROM TO - • MATERAAi, EMIPL(AA4-3�./MEMENT METHOD
�:Aquif�^rTest 0StormvaterDiairiage' � ft.
� •;��ft. 49,‘ J
ii Experimental Technology DSubsidence Control ft. ft.
$Geothermal(Closed Loop) DTraccr . 20.`DRILLING,LOG(attach additional sheets if necessary) . '—
FROM FROM TO DESCRIPTION(color.hardness.soiVenek type.grain size,etc.)
1 Geothermal(Heating/totaling Return) ElOther(explain under#21 Remarks) , ft. ft t��C ( L ��
y� (1 /l
4.DateWcll(s).Con)piefede �'' . -3H'elllD# ft. S ft. co!�
as'
Q. V' r7 o/ f{
Sa.-Well '
V `�i (� 1 1 ft .
,SR AU�Q,. LTV-1C1�r� _ h. ft. ��IV 2 :: LI�LJ
Facility;Divncr Name - - .:` Facility 1D8(i(appiicahle) '
t• n `` ft. ft.
^'7 `sz:', tk atge. GC. wAsflt..l'14 InS f;r,�;ir�n ?r<.y:� d .a 4;s
0 ss .. ft: -. ft. LJ�,d�•Ji..7..7
Physical Address.City.,aad Zip
"21REb7ARKS"� ,.,, ,kt, �.. •..� ?' " ...
�'�"� —ter1 y
County Parcel identification No.(PIN)
Sb.Latitude and'longitude in degrees/minutes/seconds or decimal degrees: -
(if well field,one tat/long is°sufficient) 22.Certi afro"n:
6.Is(are)the well(s) ermanent or Temporary.
Signature of Certified Well Contractor • Date
By signing this form,I,hereby certifrthat the well(s)was(were)constructed in accordance
1.Is this a epnir to an existing well: Dyes or t o witli.ISA NCAC 02C;0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill oiit known well consIruction information and dee nplrtin the nature of the. 'copy of this record has been provided to the well owner.
repair under 1121 remarks seGlirn or on the back ref this form. 23.Site diagrant or additional well details:
8.For Geoprobe/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-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: '�� '(D.). '24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi�"eient.(e.eaniple-3 t@100'and,2Qa l00') constructiOn to.the following:
10.Staticmuter level below top of casing: /t (ft.) Division of Water Resources,Information Processing Unit,
If water'eve!is above casing,use"+- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter '(in.)' 24b.For Inlection Wells: In addition to sending.the fonn to the address in 24a
�� above,also submit.one:copy of-this form within 30 days of completion of well
12 Well construction method: J construction to the following:
(Sc. ,auger,rotary,cable,dircetpush,etc.)
Division of Water Resources,Underground Injection.Control Program,
FOR WATERSUPPLYp��WELLS ONLY: i636.Mail Service Center,Raleigh,NC,27699-1636
13a.Yield(gpm) 10 Method of test: '\klr 24c.For Water-Supply S-lnlection Wells: In addition to sending the form to
the addresses).above, also submit one copy of this form within 30 days-.of
13b.Disinfection type: C_t4t YSL.., Amount:, 3 O. , completion of well-construction to 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