GW1--05638_Well Construction - GW1_20230831

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WELL CONSTRUCTION RECORD(GW-1) • For Internal Use Only:
I.Well d Contractor Information:/ j /1 /
3.7h rl 1� 1S 4 y/7 e A./I 14:0A'TER ZONES 2:
Well Contractor NameFROM TO DESCRIPTION•
a / y —.4 ft.
ft. J. � �,(PI�J7
ft. ft. v
NC Well Contractor Certification Number
IS::O.UTERCASING`(for.multi-,aiettWelle)ORLWER'(ifap Reable).
� ,¢/� ✓ 'S. r/r�f. FROM TO DIAMETER THICKNESS MATERIAL
41 -V Y2- ft ft 7� 4-A hz. SR II/e--
Company Name rs:
(y 3'ry ;16.1NNER:@SING,ORTUBINO(i;eothermettleSettilop4:o ./.'`, ...•.' • ..,:•.•ir, :r..:
2.Well Construction Permit#: % 7 4: 2 FROM TO DIAMETER_ THICKNESS MATi MAL
List all applicable well construction permits(l.e.U1C,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
..
Water Supply Well: ,.rf�?S'.SICRLE>�%;.<`,ii.'.t,::::::. ::.;:..'.... ; .;c:.':,•: ;a:.:•;..�r, ;•r .. .
PP Y FROM TO DIAMETER SLOTS6S THICKNESI;' m.L
I Agricultural EiMunicipal/Public a ft. ft. in.
A Geothermal(Heating/Cooling Supply) EaRgidential Water Supply(single) ft. hi.
1 Industrial/Commercial DResidential Water Supply(shared) i, cot. 5r0,: „ .<. ..,,,,, . .
Irrigation FROM TO MATERIAL EMPLACEMSNTMOD&AMOUNT
Non-Water Supply Well: 0 ft 6; 5.-- ft' /e,7jlan/&- ..e/Jll/./!y/1/1r, 3 2
®Monitoring DRecovery ft. ft. ,bdgs
Injection Well: —
ft. ft.
ill'Aquifer Recharge DGroundwater Remediation .
19 SAND/GRA'.JEL PACK(ifapplieafife)T°:`.%:.:.5.., 4't;2!,);;;: :;.`>a;;<74%:,I), ;',
at Aquifer Storage and Recovery EiSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
•Aquifer Test DStormwater Drainage ft. ft.
a Experimental Technology 0Subsidence Control ft. ft.
j'Geothelmal(Closed Loop) Tracer 20.:I)RILLING'LUG,'(ifttach additsonalbheeTeessar7)•`; . '': '.c`'
II Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO/ ', I DESCRIPTION(color,hardness,aeiVraektne anM+i a etc.)
? 0 ft. P d� ft. t� is Lru,r
4.Date Well(s)Completed: 8--/-Z 7 Well ID# 6� ft. 7 6 ft. � � /t /1 ,J „`_(,
5a.Well Location: -7Z, ft. 3 (0 ft. 4;—.441
r1r% .t
ft. ft.
,4. : t 7r.rni cr FM
Facility/Owner Name Facility ID#(if applicable) ft. ft. '..!`j�; JE L)
k ✓74.0� iA� ft. ft.
ii
Physical Address,City,and Zip ft. ft. AUG
>21':1tEMARkS'> lI e:e :L.:h:: ' .,:,:....._,... .., WA b'n;'
County Parcel Identification No.(PiN) o1/y'Q15( 1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one let/long is sufficient) 22.Certification:
4 `r/ )2,o$27N 6"/ c-cdi yc 7363 W
6.Is(are)the well(s) rmanent or Temporary Signature of Certi Well Contractor Date
Bjsigning this form,I hereby cart that the well(s)was(were)constructed in accordance
I tJ'1 ro
7.Is this a repair to an existing well: JYes or with iSA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill our known well construction information and explain the nature of the copy 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 toprovide 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: F SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 0Cif (ft.) 24a. For All Wells: Submit this fhrnt within 30 days of completion of well
For multiple wells list all depths if different(example-3Qa200'and 2@100) construction to the following:
10.Static water level below top of casing: 3 G (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I1.Borehole diameter: t/s (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: I"() 7!/r 7 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 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 4..0 Method of test: A,.//i-Ft 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
I3b.Disinfection type:C�1I�i f., e- Amount: completion of well construction to the county health department of the county
where constructed.
Foum OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016