GW1--04693_Well Construction - GW1_20230721

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: 14.�"eFFre r urll to r'Ariet' n P//� •/lC e FROMATER TONES . : DESCRIPTION
Well Contractor Name ft. ft. / 3 A J / 5�� / 1 0
NC Well Contractor Certification Number _15.OUTER CASING(for multi-cased Wells)OR LINER(if ap limbic) - ._
G� /y� / > l FROM TO DIAMETER THICKNESS MATERIAL
tr/itr mLc.[/l•j' t.(/e6/ �er'r"t`//iCe .��L I ft. 1 9�. tP/ in, o Ii)J !"vC
Company Name r�' 16.INNER"CASI�N/G OR TUBING(geothermal closed-loop)--- -
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: • t 3 gr2 0 et. rt. in.
List all applicable well construction permits(Ile.County.State.Variance,etc.) ft ft. in.
3.Well Use(check well use): 17.SCREEN •
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
OGeothermal(Heating/Cooling Supply) rkitcsidential Water Supply(single)
rt. ft. in.
• ❑Industrial/Commercial 0 Residential Water Supply(shared) 18.GROUT:,-
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. ft.
Non-Water Supply Well: ��n�nl �CIG!/��
❑Mon itoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation . 19:SAND/GRAVEL PACK(if applicable) .- •
DAquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology 0 Subsidence Control
20.DRILLING LOG(attach:additional sheets if necessary) :-,:; '
OGeothermal(Closed Loop) ❑Tracer FROM TO I DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. a.0 ft. seal C I/�
!� a 0 ft. 8 6, ft. �e/��ll� t/
4.Date Well(s)Completed: - oZ oZ g�Oft. ^�#. `cYl L�� $ r
5.We I Location: /c��®rt ^ �l/�g �Gie �L
V,�Y Y\r \ EI 1•� ft. ft.
Facility/Owner Name Facility ID#(if applicable) fL ft
rr ft.
f?I Address,City,and Z[p -- r n n n r
J
((\\ ��� REMARKS21.REARKS . JUL. • ,.r 1�"L U L
•-,., rs. �..ae...,P. 1 In:
County Parcel Identification No.(PIN) n"'" DWQMOG
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one latllong is sufficient)
.350 Igggy N 81'' 304153 w ✓e 6 --,) - a3
of ifed Well Contractor Date
6.Is(are)the well(s): ermanent or ❑Temporary By signing this form, I hereby certify, that the well(s)was(were)constructed in accordance
� with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or l3tao copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this from. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
• 8.Number of wells constructed: / construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: p2 0 0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-31te 200'and 20_4100) construction to the following:
10.Static water level below top of casing: c. 0 (ft.) Division of Water Quality,Information Processing Unit,
r If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 / ci (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
pp above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: !t 0 f6i r construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) / Method of test: �1 r 24c.For Water Supply&Geothermal Wells: in addition to sending the form to
l� the address(es) above, also submit one copy of this form within 30 days of
//13b.Disinfection type: / J Amount: 3 p f r1'a-,. completion of well construction to the county health department of the county
where constructed.
Form GW-1 • North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013