GW1--06182_Well Construction - GW1_20230922

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WELL CONSTRUCTI ON RECORD (GW-1) For Internal Use Only: i
Nt
1.WdI Contra or information: - " -
t ,
dry, rov 4 14.WATER ZONES t
WellContractorName FROM 1 TO DESCRIPTIO
1/%97w.1 2s ft. 3o ft. ,54i,..J'
/a/' ft. 70 ft. Sit,I,
NC Well Contra4.s..4.-5
ctor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
!.'(/100•01,°?5
FROM TO DIAMETER THICKNESS MATERIAL
` Q ft. U00 ft. a in. Sd‘0 /iV"
Company Name ✓ 16.,INNERCASiNGORTUBING(geothermaldoseddoop) '•!'•.
Z Well Construction Permit#: /D,- s� 4/Q -"eager SS FROM TO DIAMETER THICKNE MATERIAL
List all applicable well construction perm is(Le.UIC,County,State,Variance,etc.) ft. ft. , in.
a Weil Use(Cheat Weil use): ft. ft. I in.
Water Supply Weil: 17.SCREEN FROM
FROM TO DIAMETER I 'S_OTSZE THICKNESS MATERIAL
Agricultural ©Municipal/Public /0/ ft' /AI ft. 02 in.! 4:20 .5-4 (
CAI
Geothermal(Heating/Cooling Supply) DResfdential Water Supply(single) ft. ft. in.' P
Industrial/Commercial ®Residential Water Supply(shared) I
18.GROUT
Irrigation _FROM TO MATERIAL EM PLACEMENT METHOD&AMOUNT_
Non-Water Supply Well: 0 ft. ,0 ft. ��.
t�'r . r
__ _ - Monitoring, - - - --DRecoy"ery--__ --�_—__--__ _ --ft.__ ft._ .J _-
Int�tionlNdl: '~ _
ft. ft. - i -
Aquifer Recharge
' ©Grotmdwat ation 19.SANDiGRAVEL PACK(if applicable)
Aquifer Storage and Recover a ity Barrier FROM TO MATERIA EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage /00 ft. aa it. Mot r
Experimental Techn y Ds deuce Control /t ft. ft. ' '7
Geothermal( sed Loop) ElTracer 20.DRILLING LOG(attach additional sheetsif necessary) '
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DEscRIPnaN{mhoj�hardne s sdVtodttype grain d�etc)
.'1 a IL t2 ft. /
~Gf/ fL / ft. s.. r�-Z..., i;
4..Date Wdi s Com I aced: Wei I D# / / . Z -
5a.Well Location: tt. ` ft. ^ * �; •
•- G--//4•,jia',- �-- 4% ft. /y ft. �P � 202,3
FatHty/Owner Name - .w --> . . acilltyiD#(if applicable) o�S` ft. 76- ft. s Infdra`P.'�41 i`'r ^Fir,*!n7l't;k
- • 09f 6/�A•%/ c. .2/ ft. $ ft. G+/. - 1.J dL:Yj_ilr
Physical Ad ress,City,and Zip' l 7 f t. N. ft. fi (1�7j�,/(' f
C� REMARK '� ✓
County Parcel Identification No.(PIN)
5b.Latitudeand longitude in degrersiminuteslsecondsor dedmal degrees:
Orwell field,one lat/ong is sufficient) 22.Cer tiff c ati on:
i
.gelx.) i ..‘.,,,,,,
6.Is(are)thewdl(s) manent or EDTemporary sign of Certified Well Contractor I Date
� By signing this form,I hereby certify that the well(s)was(were)constructed In accordance
7.Is this a repair to an ecisting well: QYes or Be with ISA NCAC 02C.0100 or I5A 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 hos been provided to the well owner.
repair under#21 remarks section or on the back of this form. 23.Ste diagram or additional well details
B.For Geoprobe/DPT or Closed-Loop Geothermal Welishaving 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.
wed' SUBMITTAL INSTRUCTIONS 1
9.Total well depth below land surface: a (ft.) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths If different(example-3@200'''and 2@l00') construction to the following: I- ;
.10.Saticwater level below top of casing: la (it.) _ - Division of Water Re ouices,Information Processing Unit,
If water level is above casing,use"+^ - ' 1617 Mail Service Center,Raielgh,NC27699-1617
1L B ireholediameter: '/ ' co ,24b.For infection Wells: In additlon to sending the form to the address in 24a
• above, also submit one copy of then form within 30 days of completion of well
32.Weil constructionniehod: "nil construction to the following:- -
(Le.auger,rotary,cable,direct push,etc.) ✓ � i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSONLY: - 1636 Mail Sefvice Canter,Raleigh,NC 27699.1636
13a.Yield(gpm) C Method of test: . 24c.For Water Simply& Inimbi:3n1. fWdls: 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: 7 completion of well construction to the county health department of the county
where constructed.
1
Form GW-1 • North Carolina Department of Envimnmental Quality-Division of Water Resources I Revised 2-22-2016