GW1--05977_Well Construction - GW1_20230918

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well.Contra or 1 nfor/ 4
mation:
44+s c,/ CO
14.WATER ZONES
FROM TO DESCRIPTIOI
Well Contractor Name 07C ft. Jo ft, f9'
4/99' T ��Js ft. /4 O ft.. .;:��
NC Well Contractor Codification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
litrv✓ ( 1O <'�� 5 F0 ft. 1;00 ft. DIAMETER in.
THIGRIE0 v MATERIAL
t.ompanylName ' J ��? 16.INNER CAST NG OR TUBI NG(geathermal dosed-loop)
1W
2.Well Construction Per mit#: �,2044, -,/61076r FROM TO DIAMETER THICKNESS r 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.
17.SCWater St.lpply Well: FROM 4EEt TO DIAMETER SLOT SZE THICKNESS MATERIAL
a Agricultural OMunicipal/Public Av ft. oft ft. , in., 2O �6(4t0 , ,
I Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) " ft. ft. in.
It Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. to p ft. ./ "Owe'
is Monitoring Recovery ft, ft. `7r./F
Injection Well: - ft. ft.
I Aquifer Recharge OGroundwat • _ diation 19 SANDIGRAVEL.PACK(if applicable)
N Aquifer Storage and Recove a mity Barrier FROM TO MATERIAL EMPLACEMENT EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage /DO ft. Oaf) rt. Yj o, ��./-
*Experimental Techn y OS "dence Control ft. / ft.
II Geothermal( sed Loop) Diracer 20.DRILLING LOG(attach additional dims ifneoe ry)
FROM TO DESCRIPTION(crolo hardn vel/csk tyge,gain size,Hal q.
it Geothermal(Heating/Cooling Retum) Other(explain under#21 Remarks) a ft. y ft. fAr -.✓ `L.. 1 t f 4
4.Dale Well(s)Completed: 7.' ' Well I D# ft.h? ft.
73,5a.Well Location: ft. /f ft. ✓� S U' 1 8 2823
fI' itI 4t r�''1 O a/f ft. /4/ ft. InfOryf'ar?�1 i'r.--c:fh�::. l::-r
s" ft. 6 ft. ` Cr Cl:.t
Facility/Owner Name
/�3 ® Facility ID#(if applicable)
7 .! J
50 e. 5411Ai 6 'Y/�iC .2/- � ft. S ft. 4/
Physical Address,City,and Zip �/ ft. h ft. /1 7"
016574
511 )REMARK ,
4-
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degr ees/minutesisecondsor decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: ,
N W64010 c• 2•G-7,"
6.IS(are)thewell(s):_er
,.���,,.,�manant or Tefrtporary Sign to of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.I s this a repair to an existing well: 0 Yes or 10 with ISA 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 tinder#21 remarks section or on the back of this form.
. 23.Ste diagram or additional well details:
8.For GeoprobelDPT 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 I.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: ,2� (ft.) 24a. For All Wells: Submit this form within,30 days of completion of well
For multiple wells list all depths if different(examp a-3rir2011'mid?ar100') construction to the following:
• 10.Static water level below top of casing: (ft.) 'Division of Water Resources,I nformation Processing Unit,
If water level is above casing,use"t-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Boreholediameter: (in.) 24b.For Iniectien Wells"In addition to sending the form to the address in 24a
/, a� above, also submit one copy of his form within 30 days of completion of well
/3
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable.direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSONLY; 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) I Method of test: 24c. For Water Supply& Infection 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: Amount: \3 L completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016