GW1--04779_Well Construction - GW1_20230724

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WELL CONSTRUCTION RECO (GW-11 . For Internal Use Only: • .
1.We11 ••ntr. •r-Iniv f=' •
a' • 14.WATER ZONES
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Well Contractor Mire FROM TO DESCRIPTION
. " 3 S35 • . • goo �• 5'�fc "
ft. ft. • •
NC Well Contractor Certification N er 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)TE •
FROM TO DIAMETER THICKNESS
h MARIAL
`� LVL Q/J� `�� ft. ft. in.
Company Name
0
.� - ^C 16.INNER CASING OR TUBING(geothermal dosed-loop) •
2.Well Construction Permit#: C2- 2/ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) f./ ft /OD ft* ,67/dEr°' 7-1 1 l'e(,L 19V-L---
3.Well Use(check well use): D' D' 1° • .
Water Supply Well: 47.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
• ❑Agricultural '❑Mtmicipal/Public • ft. _ ft. ... In
ID Geothermal(Heating/Cooling Supply) idential Water Supply(single) fc ft in.'
❑lndustrialCommercial Residential'Water Supply(shared) ,18.GROUT
•❑Irrigatiolt ❑Wells>100,000 GPD FROM TO MA EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 3 ear !i.L`' jd ( ��
❑Monitoring ❑Recovery ft. fc / p 7 �s.L
' Injection Well: r � ` �m/
ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACIC(if applicable)
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❑Aquifer Storage and Recovery • ❑Salinity Barrier • ' ' FROM TO MATERIAL _ EMPLACEMENT METHOD
❑Aquifer Test. ❑Stormwater Drainage is ft.
❑Experimental Technology ❑Subsidence Control " • ft• R. •
• ❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO . " DESCRIPTION(color.hardness,soiVrock type,grain sae,etc.)
0 Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. is
4.Date Well(s)Completed: 7 7- 2.3 Well ID# • ft •f
f 6n74.t.-1:DSa.Well Location: •
. Qi Sr_ f. ft:
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• Facility/Owner Name Facility ID#(if applicable) fe ft.
B-X)Y11A1 I ? - ear RA • 14-l 3 7- -' •"f� ft r7.1 _•r"r:.iTt I l-
Physical Address,City,and Zip ft.' ft. i e es i./ a 8....s.
CCoo tt K 21.REMARKS/ JUL 2-4 2023
ty Parcel Identification No.(PIN) •
ist5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ifltsOlTPi;D t'fs 3G �t IRS
(if well field,one let/long is sufficient) 22.Certification: �3�3 .C.;
3/., j 2' 51.1.,• N .SO . .cf .• I b '
f.__
. ,i. tortpot- 7-?ff- 23
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6.Is(are)the well(s): Nrmanent or ❑Temporary Sig ,- •Wei Contractor Date
1 r l i •
v/ C) By signing this form,I hereby certify that the wells)was(wire)constructed in accordance with
7.Is this a repair to an existing well: ❑Xes or to 15A NCAC 02C:0100 or 5ANCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out brown well construction information mid lain 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: t'� 24.SUBMITTAL INSTRUCTIONS •
9.Total well depth below land surface: ✓ O ft Submit this GW I within 30 daysfollowing:
ip if different(example-3Qa 200'and 2Q100� ( )
For multiple wells list all depths of well completion per the
10.Static water level below top of casing. [p ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),•
If water level is above casing,use"+' (/ ( Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 •
11.Borehole diameter: • ( If 0 .(in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
• L Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: lS"1 Z ti. • 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
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• FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
/� � Permit Program, MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) (-+ U Method of test � ' - it
13b.Disinfection type: • 14114- Amount: to •61.-----