GW1--05065_Well Construction - GW1_20230804

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WELL CONSTRUCTION RECO (GW 11 For Internal Use Only. •
• 1.Well Contractor•Information: •
c .- p r-4,—,s- '14.WATER ZONES
Well Co lot •.e • 4--,e,,P�d ,f •K FROM. TO DESCRBIION
�3 5�3 s �.., ft. -35
• �5 o � ft . ,
AUG U d Z023 ft rt
NC
Well Coatraaor Certification Numb t1- 15.OUTER CASING(for multi-cased wells)OR LINER(if ap liable)
/ 'n-14,::,`�S�iay� i9f�ey C'^-3 OR t FROM TO DIAMETER TSICiQ`tESS MATERIAL
J(/ld1YY)CtAVt. cm :.; ft ft in..
CompanyName
16.INNER CASING OR TUBING(geothermal dosed-loop) •
2.Well Construction Permit#: 3 76 5 • FROM To DIAMETER TBIC trrass MATERIAL
List all applicable well construction permits(i.e.WC,Cotoy,State,Variance,'etc.) 't) f. 3/�/ it GO( in'. �i' k. r'
3.Well Use(check well use): • ft ft in. 1
Water Supply Well: • 47.SCREEN
❑A Cultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL '
gn '❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) idential Water Supply(single) ft. ft b.'
❑Industrial/Commercial ' ❑Residential'Water Supply(shared). 18.GROUT
❑hrigation • ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft ^ ,
• ❑Monitoring • ' ❑Recovery ft Z 3 ft /V /�/L,7G e
• Injection Well: F r•�'�:K: r —
❑A utferRech a ft ft l
9 ❑GroundwaterRemediation
❑Aquifer Storage and Recovery ❑SalinityBarrier 19.SAND/GRAVEL PACK(if applicable) • •
FROM TO MATERIAL EMPLACEMENTMEIHOD
❑Aquifer Test ❑StormwaterDrainage ' ft , ft
❑Experimental Technology OSubsidence Control ' , ft. ft
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• OGeothermal(Closed Loop) , ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO • DESCRIPTION(color,hardoea,soil/rock type,Brain size,etc.)
ft ft:
4.Date Well(s)Completed: 7'LY'2,3 Well ID# ft. •R.
5a.Well Location: ft. it
• Mcs'�1� AA.) tSSV e • •
ft ft.
• Facility/Owner Name Facility ID#(if applicable) ft. • f.
kW •g q A3b - 12 tit . CD i'l11 w()64 -"' ft
Physical Akdress,City,and Zip
t5 ft.
t ) !� ,21.REMARKS/
County Parcel Identification No.(PIN) • • '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient)
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22.Certification:� i � �� N �D' • 2z —� r Wti.
"2' 2
.6.Is(are)the well(s):,'ermanent or ❑TernPorarY lvD Signature otifiedell Contractor
Date
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Bysigoing this Jam,Ihereby acre),that the well(s)war(were)constructed in accordance with
7.is this a repair to an existing well: ❑Yes or 4fo ISA NCAC 02C:0100 or 23i1 NCAC 02C.0200 Well Construction Standards and that a copy
"this is a repair,fill out brown well construction informotfon an exxplain 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 Rdniarks Box).You may also attach additional pages ifnecessary.
drilled:
3 I 24.SUBMITTAL INSTRUCTIONS •
9.Total well depth below land surface: (ft)
For multiple wells List all depths ifdj/Terent(example-3(Qa 200'andl@100) Submit this OW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: O O • (ft) 24a. For All Wells: Original form to Division of Water Resources.
Ifwater level is above caring:use"+i Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 • (DWR),
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IL Borehole diameter: (0'/1( .(in.) 24b.For Injection Wells:Copy to DW1t,Underground injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.'Well- 'construction method: S 15 {�•t y�.
(r e.auger,rotary,cable,direct push,etc.) ( 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health department of the county where installed
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• FOR WATER SUPPLY WELLS ONLY: •
q 24d For Water Wells producing'over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(Rpm) 3 A Method of test CA.Ati". Permit Program,1611 MSC,Raleigh,.NC 27699-1611
ft
is
13b.Disinfection type: l k]. • 'Amount: ' (0 .11f • i• •
Fong GW-I
North Carolina Department ofEnvironmental Quality-Division nfW.•.."v_...____ -