GW1--05640_Well Construction - GW1_20230831

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: .
1.Well Contractor Information: ,
I)a 1// GL Ct LYVLp 1l14:'WATERRZONES >' M �?'Atx'l;a. i".' Ot4-rk OMO. �1t-2>,. � . ''.
j FROM TO DESCRIPTION
Well Contractor Name Cp/ ' fft. I
/J A ft. f. 1 '
NC Well Contractor Certification Number /� ,k15:311TER;,G�ASINCs,`(fbCmdltl-csieillwe114011tII NERt(iftap`Usable) ' lid"A'Y'rt r;:}
� e W I C/ yJ�ine CD'
G FROM TO DIAMETER THICKNESS MATERIAL
Company Name r
II'' 1- S l'6 NNER C ASING':URNS[JBINGi(y+i thermaltelaea=loop)1 it :k"tcz:s
2.Well.Construction Permit#: ILYgl°, OA• " n D 1'r .iey1 OM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,.Variance,etc.) [t. ft. ( { in.
3.Well Use(check well use): • ft. ft. I In.
rll7 SCREENIME u 1 sWA%1',t""5:i-.'...,M. 1.lkit tsi` ;w 4r`7- 1.i47 ti i
Water Supply Well: FROM TO DIAMETER SLOT SiZE THICKNESS MATERIAL
__ 3Agricultural - - -- ----- --OMunicipal/Public,- --.-. - - ..: :.ft. ft.. _. In. . .
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. n• In-
O Industrial/Commeroial X Residential Water Supply(shared) 1418 GROUT } .aailA r,,,t+: 1r+ Y:w ,_i7 N rt°.. x.MW-t,'ra 05M-ki is
,Irrigation FROM TO TERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: a ft* a2° ft• he1'iteiU e )`. 1)'Is- �)D ure-di
Monitoring ' DRecovery ft. 'ft. I! /
Injection Well: - ft. . g
•
E3Aquifer Recharge ',N, Groundwater Remediation I'
-,19 SAND/GR7l�v,EL PACK?(IfraipllsAble)..61V.+s1`Xs:'>§`s fei `:csto" ,
Aquifer Storage and Recovery ' 0 Salinity Barrier FROM TO _ MATERIAL EMPLACEMENT METHOD
QAquifer Test 0Stormwater Drainage ft. H' • I
DExperhnental Technology 0 Subsidence Control ft. ft. I' .
Geothermal(Closed Loop) E3Tracer gi28:DRI:LINGaLOGY(attacti}dddltiorialGheetrl[neceleary)r v3'3�r"`r"r 7.`tiAt ' m.
FROM TO DESCRIPTION(color,hardness,sad/rack type,grain dze,etc.)
DGeothermal(Heating/Cooling Return) [Other(explain under#21 Remarks) fG fG I I
p (� /r. ra.vei
4.Date Well(s)Completed: t-/�GG3 Well ID# 6 5- fG ,r(Q( )4n /Pr
ft. ft.
' 5a.Well Location:
Facility/Owner Name Facility ID#(if applicable)
H. ft. . 1
C*r2.!. DV 5 -Kt✓ ./ fie- f ' . AUG 3 1 2023
Physical s,City,and 7AP ft. 1 ft i t. -r a
l u r�Ce, #°21:eEMAKics r+l v k_ >:Ys l ytw:! r!it-t' «'t s",;<";:::;$�$ Yt C- --- ----- i
r �>
County Parcel Identification No.(PIN) 1'
1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
. - (if well field,one lat/long is sufficient). _ - - 22.Certification: - -- . ___.._ . - - .--� -
5 /3,-6S3 N '--J1, 5'40 9'64 W iji c
1- I6-
6.Is(are)the well(s)i.'f,Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify' that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well:• X Yes or gliNo - with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out 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. I
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop1Geothermal 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: �C SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �(/ (ft.) r
24a. For Alt'Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths Ifdifferent(example-3@200'and 2@100) construction to the following: I
o !
10.Static water level below top of casing: /) d, (ft.) Division of Water Resources,Information Processing Unit, ,
If water level is above casing,use"+" /-1.-
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: In add i
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: JA0171/1 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) I -
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service i ei ter,Raleigh,NC 27699-1636
13a.Yield(gpm) 1-I Method of test: ei--/ k 24c.For Water Supply&Injection Wells: In addition to sending the form to
II- the address(es) above, also submit'one copy of this form within 30 days of
13b.Disinfection type: LYl 1 b r I /� Amount: Gb�5 completion of well construction to the county health department of the county
where constructed. 1