GW1--04712_Well Construction - GW1_20230721

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: '
1.Well Contractor Information: j
.l 4 Int P 6 0 I t
la WA?TEIVZOIVES ., ,., .> _. .....
Well Contractor Name FROM TO DESCRIPTION
alq ft. j 7O ft. �9 P
l 1 ft. r 3 0 ft r �i f r •
NC W l Contractor Certification Number 15.OIJTER C;A75/IlYG(formal(ti-case_itiells).QR=LINER<(tEapph"cable)
&11(C foods. call ° (�i)�
,'r�, P�. tnq FROM TO DIA��IET R THICKNESS MATERIAL �`
U I • �,`� V ft. a, ft. C{I tl in. 0 1 d) /l lc
Company Name } C
16.:INdVER Ci1SIlYG OR TUBING({;ebthermal closed loop) ..-. ..i
2.Well Construction Permit#: C 0 P lull° 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 E TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public it. ft. in.
❑Geothermal(Heating/Cooling Supply) ij tesidential Water Supply(single) ft. ft. in. `
❑Industrial/Commercial ❑Residential Water Supply(shared) is„GROt1T
❑Irrigation ❑Wells>100,000 GPD 1 FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: b! ft. Z® ft. ,ezntad+) j r4Vrt
❑Monitoring ❑Recovery ft.' ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
a.19.-SAIID/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology OSubsidence Control ft. ft.
D Geothermal(Closed Loop) ❑Tracer 2W DRILLING.LOG(attack additional sheets If necessary) -
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ® ft. J?® ft. � l�ti -
4.Date Well(s)Completed: 7 - 12-23 Well ID# 3® ft. !J�,i 0 ft. q ret n ti- d o c.k
5a.Well Location: �/t� 1 ft. it.
WI \S)0vJ J r° 6 ft. ft.
ft. ft. r
Facility/Owner Name C p Bn�� Facilityrr ID#(if app licpable) P:3
US eo !t QaSe 616 Youn 3V6�t`J ft. ft. •
k .64""' L.Y yap
Physical Addddress,City,and Zip / ft. ft. JUL 1 1 7023
Fr ti4 i!1 21:RR14L4RIcs : .-, . .,v_ titiEr ,
lea Prt Urt F
County Parcel Identification No.(PIN) 7b
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/iong is sufficient) 22.Certification: I ']
N W j', G'l 1. ,2t—J3
Is(are)the well(s)• termanent or Temporary SignaturCertified Well Confj..---
6. tor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or E15to 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the 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 Geoprobe/DPT or Closed-Loop Geothermal Wells having the same ' You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: i 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100)
� ) „. , 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: (in.)
24b.For Injection Wells: Copy to,DWR.,Underground Injection Control(IUC)
� Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 01/4_( r if 6a Y 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
-L iO J' Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: f'it rl Amount:ji i i b
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018