GW1--05433_Well Construction - GW1_20230821

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WELL CONSTRUCTION RECORD GW-1 For Internal Use Only:
1.Well Contractor Information: i
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14.WATER ZONES-. , t !.:. • ' .
1 FROM 1 TO DESCRIPTION
. Well Cenhactor Name
- 44.4,44 ..(.07 • . . . ft. ft. t !
ciI
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ft. ft. '
NC Well Contractor C'ettifientio Number
. . . IS.(Ram CASING Obr multi-eased wells)OR LINER(if ep ;legible) -
FROM '1'0 DIAMETER THICKNESS . MAlERLAI:
6) D. iiie t,?'' D. - ,.,2 ',I/1. S'64 ,o's,) iliApjc. .
Company Name .
• . IN.INNER CASINO OR TUBING:(tieuthermal closed-Ion.) •,"--- . ' ' , • •
2 Weil Cons-truction Permit ti: ,.....rnh roost To .._..,„ THAW RR; TIM KNESS . MATERIAL
n, I 44, . ; in. , Ia .L.:I of;iy,t:plfc,:tte.well iriaiiiiiiiii:1 Fil--''11 .El:C.Cetcrtny y.tsitE t,41tL;
\1.... _
3.Well Use(check well use):
\Water Supply Vt-ell
FROM 10 DIANIE1 ER -SLOT SIZE THICKNF.SS MATERIAL
DAgricultural .Eij,Liv dnicipal/Pub.%procrsiilet'A Uret/joft. /.50 ft. 02 iri. ,,i 0 Sc4.#° ,i-ic .
, Geothermal(Heating/Cooling Supply)9 Resi„,,,,,,r , ..„„,,..,gie, n. ri. im /
- , Industrial/Commercial• OResideittial Water Supply(shared)• 18.caour,
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rlinitzation FROM TO MA'TER1.11. EMPLACED ENT METHOD dr AM CH1NT
Non-Water Supply Well:
Monitoring
Injection Well: ; • .
DRecovery
. ft. ft.
- ft. ft. / •
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, --- Aquifer Recharge „ . . Oaroundwater Remediation ' ) ft. - °--ft' ' I.- 44 - ---- --LAir-
Atutift.r Storage and Rein • ry 9Salinity Battier
i.19.SAND/GRAVEL PACK.(if applicable) ' '•.; '. • --
FROM I '1'0 MATERIAL,
- 1 1 r)• _. .
1 li.MPLACENI ENT MEI HOD'
-Aquifer lest ,
Experimental Tech logy
Geothermal used Loop)
(-- Geothermal(Heating/Cooling Return)
DiStormwMer Drainage
Subsidence Control
DiTra — tt.
'••20,DRILLING LOG(tittach ndditlimill Sheets if neecssaiy) ' ' '
FROM . Ti) -DESCRIPTION ten r.hardness.sell/reek type,antis sure.clef
DODler(explain under 421 Remaels) '-'22' i-7. 1 .°
____19 •ft. 2
4.Date-Well(s)Completed: r3 .Well ID#1 1 (1
1 j ft. ?0• ftiii_4a.;
5a.Weil Location: .
/1." _5,,--7 ft. ex.:, L ft. •
Facility/Owner Name . - Facility LIM tif applicable). gy ft. /s9 ft.
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PhYsical Addres.City.anti Zit')
21REMARICS., ,,,,,...„ ,' -' • -• ' . . .- .
,.k 43 4tf)
County . Par Identification No.(PIN)
5b.Latitude anti longitude in degrees/minutes/seconds or decimal degrees:
Of welt fiekl.one tat/long is sufficient) ' : 2.Certification' .
W
*LP.-1/..._.
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Signature of Certified Well Centmclor , Date
_:5„1.slatrc,)till_c,"tt:e.:1(slajr,t1T,1413citt. arcrialtv...” _ ._ _
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• r<7 _ By signircir this firm,I hereby cent&that the m.:116.:t was(were)comma:led in(la-embrace
7.Is this a repair to an existing well: plies or .'o wirh 1.51.4 NC:IC 02C.01(10 ur ISA NC-IC'02C.0200 Well Cimsrntetion Standards and that a
Olds is a repair,.fill out known well construction itdOrmation and cap/air;the nature of the cum of this record has beet;provided to the it'd]owner.
repair under#21 remarks section or on the back of this form. .
23,Site diagram or additional well details:
You may use the.back of this page to provide additional well site.detail.or well
S.For Geoprobe/DP'F or('Inset)Loop Geothermal Wells having the sense
construction details. You may also attach additional pages if necessary.
construction,only I CiW-1 is needed. Indicate.TOTAL NUMBER of wells
drilled: . SUBMITTAL INSTRUCTIONS !.
9.Total well depth below land surface: /. -4) (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different frxampl-3(4`200'and 2(d)100) i
construction to the following:
10.Static.water level below top of casing:. 7 3 (ft.) Division of Water Resources;Information Processing Unit,
limiter revel is above ca.sing use"-i- 1617 Mail Service Center,Raleigh,NC 27699-1617
U.Derelitilediartieter:L• ..)
241).For Iniection Wells: in addition to sending the form to the address in 24:i
, .„9"4/1.„ above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: ,t;',7 4, ,fr Cr, construction to the following:
(i.c.auger,rotary,cable,direct push.etc.)
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Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cetiter,Raleigh,NC 27699-1636
13a.yield(gpm) . Method of test: .1: 9
/—r= 24c. For Water Sunnis-& injectini Wells: In addition to sending the turn to
/ .., .the addressies) abeve, also submit et nel-copy of this form within 30 days of .
13i).Disinfection type:e d.....,. .. .Amount: ..„,/ a 7".Z. completion of well coirsituctiolt tel the'county health deparunent of the county
where constructed,
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Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016