GW1--05699_Well Construction - GW1_20230905

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor <
Information: �(�
Jt Ck�\SCn 6l )St-" \ .i4 WATER7.ONES ._:"9.- R?<t. - _.
WellCoutractotName FROM TO DESCRIPTION
�{� 3 _ U " 33C ft -I-f4.t(c)�
33cft. yir ft. i- '\1c
NC Well Contractor Certification Number .-15 OUTERCASIPIG;(foTmuld-cased.ifells)ORLINER'(ifalieatile) :'I' . '
(,c) prI� IJ��Y, a p i �C ' FROM TO R DIAMETER THICKNESS MATERiAL
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Company Name ':16„NNER CASING OR TUBING'(geothermal closed-loop)' _ -
2.Well Construction Permit#: 0 55- a C 3 O(OS S. FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft. ' in. �- ^
3.Well Use(checkwell use): ft. ft. in. l�
Water Supply Well: 17ii-SCREEN �: ,:_' ";:.' '=.; .` : -,_
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural lD-'M cipal/Public ft, ft. In.1 i
a Geothermal(Heating/Cooling Supply) RAesidential Water Supply(single) ft ft. iin.l
*QndustriallCommercial (Residential Water Supply(shared) 18:`GROUT "'
E. Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: -- - ft, ft. - - _--
N Monitoring [i°Recovery ft. ft
Injection Well:
ft. ft•
2111 Aquifer Recharge E3Groundwater Remediation
=.19:SAND/GRAVEL PACK(if applicable). "-s _ 3
W i Aquifer Storage and Recovery 0Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
**Aquifer Test DStormwater Drainage ft. ft.
WWiExperimental Technology 1°'Subsidence Control ft. ft ''
111 Geothermal(Closed Loop) °Tracer '_'20:'DRILL-ING LOG.(attach'additional sheets.if necessary)
(]jai Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
FROM To�1 t DDESCRIPTION(rotor,hardness,soil/rack type gram size etc)
2Ocft. -dJr ft '0,r“-{'C___
4.Date Well(s)Completed:g-i-I-23 Well ID# ft. ft
•5a.Well Location: rr AA R' it �--
1 <^iIYC)`�'11 l_[A ft. ft. j 1 i j �tX"'?t" r"
a�
Facility/Owner
N e Facility ID#(if applicable) ft• ft•
't 3 3 Sk Pal Mi k5 pi vrpi AK. �,P1.s`c7
ft ft. SEP a 6 2023
Physical Address, V\tip City,and ft. ft Infor,�,aa+ n ?rr-i..1ti p ti
a�,
Xv kil vs \ "21 REMARKS r --;a c- it. .f:" . . 7it,,t,7 F,'3Dric ..a (, t„-
County Parcel IdentificationNo.(PIN)
I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(-Ewell field,one lat/long is sufficient) 22.Certification:
5P got 31. R-14 t N 'V o 3 L'S 5-cirri w '1'. .�— ►-7-23
6.Is(are)the well(s) ermanent or Temporary
ignature of Certified Well Contractor Date
By signing this form,I hereby certtfy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or °No with 15A NCAC 02C.0100 or 15ANC4C 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 ofthis 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 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: sTTRNrrrrAT.TNgTrZWTCTrONC
9.Total well depth below land surface: 5 a S (ft.) 24a. For All Wells: Submit tliis form within 30 days of completion of well
For multiple wells list all depths if different(example.-3®200'and 2@100r) construction to the following:
10.Static water level below top of casing: 10i0 (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 diameter: (•0• ZC (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: �W<
L,, y above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) 4
Division of Water Resources',Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service'Center,Raleigh,NC 27699-1636
13a.Yield(gpm) i J Method of test:gar- CC ' t21 We- 24c.For Water Supply&IniecItion 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:OR Inn 1^-2 Amount: 5 -1-abs completion of well construction to the county health department of the county
where constructed.
1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016