GW1--05900_Well Construction - GW1_20230918

i 1 IIIKI V
WEY.I.,CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: l\`,
MI6?' /6-6( D 14.WATER•ZONES
Well Contractor Name FROM TO DESCRIPTION
`I s xP -,d , /ra d14," .Z i✓ -A
mom om /5 f t. 71/,40_, 416ref3 C/A'J
�'�L ft. ft. 1 , r
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
f e ����y�/'•fG� FROM TO DIAMETER THICKNESS MATERIAL
M 4 // ,..1-.?....ft. 3 .P3 ft. / in. 4'�� �� Ft/
CompanyNameI (� eJ `
t a. 16.INNER CA NG OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: �� c©3 ( FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) • ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO ft'
ft,
DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Q M icipaVPublic ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. in.
i Industrial/Commercial Residential Water Supply(shared) 1R GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. Zt, ft. 1- .,'
i . � ' 47-,
Cp ., / �;1,Monitoring lRecovery ft. ft.
Injection Well:
IIIAquifer Recharge QGroundwater Remediation ft. ft. -
�Aquifer Storage and RecoveryDSalinityBarrier '? 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
III'Aquifer Test }Stormwater Drainage ft. ft.
•i.'�Experimental Technology DSubsidence Control ft. ft.
II Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary) •
1 Geothermal(Heating/Cooling Return) ! FROM .TO DESCRIPTION(color,hardness,soWOrock type,grain size,etc.)
( g Other(explain under#21 Remarks)
/ G ft. ii /if 4>ft. �y ,y of 4'Lire
4.Date Well(s)Completed: ( G-G Well ID# (IJ ft. / ,aft. 4 I c
5a.Well Location: /j3 ft. Z_a',ft. /,, r,0,, ram•
I 1 P..)/ it't�, ft. ft. -
Facility/Owner Name • Facility ID#(if applicable) ft. ft. I
I 4
Fy _F•"":` rj,, d I',,,q
! ft. ft. %4...., �.r r....i. V t1....d J
- O A. i1- _\mac 5 C J-kir-6 e P` '
Physical Address,City,and Zip • ft. ft. S E P 1 8 2023
': i(.' `��ery 21.REMARKS .,
P .County Parcel Identification No.(PIN) iota 71; '?'^t1 c,-,.. .4 .glint!
[Ar i l.:;3;23
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22. er(ifica'on:
8 �0 3
6.Is(are)the well(s) eanent or Temporary Signature of Certified We on ctor D e' Prm
By signing this form,I he e y certt&that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes .or No with 1SA 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#2I 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 details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also'attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ZOO (ft) 24a. For All.Wells: Submit this farm within 30 days of completion of well
For multiple wells list all depths ifdteerent(example-3@200'and 2 a I00') construction to the following:
10.Static water level below top of casing: '(ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"4"
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Alf-.
l '
12.Well construction method: t°" above,also submit one copy of this form within 30 days of completion of well
r construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)r
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: /� 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) _ Method of test: F(', / 24c.For Water Suably&Iniection'Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
p
13b.Disinfection type: -6cic; Amount: 0 C completion of well construction to the county.health department of the county
- where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources t ' \ Revised 2-22-2016