GW1--04887_Well Construction - GW1_20230728

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r Print Form
WELL CONSTRUCTION RECORD(GW-ll For Internal Use Only:
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1.Well Contractor Information:
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1;4:•1?trATER.7.0NES
• - 7arir�/ y FROM TO • DESCRIPTION
Well Contractor Name, U ft. ft.
4S/-t f�}1 ft. ft.
NC Well Contractor CottlSootion Number 15,•OTl'FgR.CAS1g!1•�.(foe•mulN�oasedwelts)UItLINER'(:!nap cable)
/, 1 r FROM I T/9J/1 /DIAMETER l TmCKNES3 MATERIAL
61-11//114IIV�://��i�m �b•/y�G• ft 1 .!'7 f' W,/ 5 ln. 1 E5DYj,ZJ p Vc.
Company Name i 16.' II:CASING QR I1B):IVl3tRedtherml'atalosed-loop)
L-�/ �.3 ���
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. la. •'
List all applicable well construction permits(l.e.UIC,County,State,Variance,etc.) it.
Et. ft. In.-
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3.Well Use(check well use): .
17.SCREEN: •
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural .DMunicipalfPablic ft. ft• In.
Geothermal(Heating/Cooling Supply) ljattepldential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18..taRQ.UT•,
Irrigation FROM TO MATERIAL� EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: (0 ft. A b ft. , e.rLl e°. tite J 6 w'dA 1 3 b1•'
Monitoring ORecovery • ft. ft.
Injection Well: ft, ft.
a Rechar
Aquifer Groundwater Remedlation•
q g .19.SAW/GRAVEL FACK(it'applicable)•
Aquifer Storage and Recovery .% DSalinity Barrier - FROM , TO MATERIAL EMPLACEMENT METHOD
Aquifer Test •„��••,
DStormwater Drainage ft. ft.
:�A? [t. IL •
Experimental Technology 0�. DSubsidence Control
Geothermal(Closed Loop) Tracer 2o.•DRiLLiNC,LOG.(attar'h'addiNDnal.aheeta:tfaeeeseaay)
(Heating/Cooling Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,eoWrock type,grain else,etc.)
Geothermal Heating/Coolin Return) ( p ft• !1 ft• i 1^ G���
�j ppryry ,y d �1 ,._(
4.Date Weli(s)Completed: /`/'oL.7 Well ID# IL '/O�/'-ft• �)"�1L1 J
ft. ft.
5a.Well Loc lion: _
�{ ft ft.
i iyn > eAcriv,,o/alit �~e
Facility/Owner Naefn Facility[Dil(if applicable) ft. ft. R E. ;f„,
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i PGL)/ 4-Pl o©re.• ��-• ft. ft. JUL L 2 Z023
Physical Address,City,and Zip l
Pbl J/ • 2f.REMARKS 161`�rr;
County
Parcel identification No,(PIN)
5b.Latitude and longitude in degrees/minutes/secontts or decimal degrees: '• .
(if wall field,one lat/long is sufficient) 22.Certlfl tlon:
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.W3I4I/ N ' 92-r 05- 63 W i.' / 41 r. S-a 3
Signature of Certified Well Contractor Date
6.is(are)the well(s)j'I'Permanent or Temporary• .
By signing this form,1 hereby certl(y 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
f Is this a repair outto known
existingwell well:rYee o >!No copyof this record has been provided to the well owner.
If this!s a repair,fill /Drown construction information and explain the nature of the
+dash under 1121 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geogrobe/DPT or Closed-Loo jr;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: • •$- �J r SUBMITTAL INSTRUCTIONS
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9,Total well depth below land surface: A Q.7 (ft.) 24a: For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths((different(exatrple-3(g,200"and 2@100) construction to the following:
10.Static water level below top of casing:e I e& (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diamethr: GO ( '). 24b.For Infection Wells: In addition to sending the form to the address in 24e
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: rd Gt-r Y construction to the following:
(i.e,auger,rotary,cable,direct push,etc.) /
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: ` 1636 Mall Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) Method of test: a-I 1" 24e.For Water Supply&Iniectlon 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: ek)0 VI h P Amount: C b.(Q_ completion of well construction to the county health department of the county
where constructed.