GW1--06223_Well Construction - GW1_20230925

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: . i
1.Well Contractor Information: '
lit 60tn a�
ur14ry1'EIT.ER`bl?lY...„.�a'„:„....„. }._, ,_a..? E.>; .a.:...`,: ..*.p;;,.iL,.
FROM TO DESCRIPTION
Well AContractor Name
D�� 1 ft. D® ft
ft. ft. ..
NC Well Contractor Certification Number
`.t19 OL•FT`15R C'rC5IlYG(for:irr7iltt cased wells)UIr:EINER{ifap hca6iW MgtMc
G^.r FROM TO DIAti1ETER' THICKNESS .MATERIAL.
" 11 o Poo e- �e/\I 1. � � ft. 10 ft . in J
Company Name, r P Y
p., x16xINNE MCSILC#s6I�:T.i niN.fd(6iliermal;elused loop) : ,.:.z,4A' 4� r:s .._.:
2.Well Construction Permit#: 6111,1 05113).- ID'L 3 FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(Le.UIC,County.State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 4.17ES pri?,W ,t MirN, 'Y4 .._;: - , _ .V Y x t;v..
FROM TO DIAivIETER4 I SLOT SIZE THICKNESS r i MATERIAL
❑Agricultural unicipal/Public ft. ft. in; '
❑Geothermal(Heating/Cooling Supply) ilt Residential Water Supply(single) ft, ft. in'.
Dindustrial/Commercial ❑Residential Water Supply(shared) ai8r: 12oT3`i'l*``..k.a g: ;..'.., ._>r _* n �ivt :,... :"; fg;;;-_:t,:
❑Irrigation DWells>100,000 GPD v, FROM TO MATERIAL EMPLACEMENT ETHOD&AMOUNT
Non-Water Supply Well: 0 ft. 1® ft. J ei li-ei ea% ' Y
❑Monitoring ❑Recovery ft. ft. `
Injection Well: -
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation < r
FAST WA W1GRAYELVXCK(iChppLNebTg)r s d_ wP.. ,; ? ,_ c,,� W ,.t,,.,:. s k:t;
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
' ❑Aquifer Test ❑Stormwater Drainage ft.' 'ft.
❑Experimental.Technology ❑Subsidence Control ft. - ft. •
❑Geothermal(Closed Loop) °Tracer '2U."IiRI L NG I;0Wfittacb additiot nl"sheets tf'nec ssdryT Mri;r c ' ?>ga:;. '. •
FROM TO DESCRIPTION(calorthardness,sotVrock type,grain size,eta)
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) el ft. 2 D ft' 4.IY
4.Date Well(s)Completed: Y-19a Well ID# a 0 ft- -7 0 0 ft J ('d I/J1 t-e (rb vj=
5a.Well Location: ft it.
fr. , aft.
Facility/Owner Name Facility ID#(if applicable) s Z _L � t!h ")
45104 6E4,1 iiorrI3 r(,Uel,(<2 1e3t ft. , f� SEP Z023
Physical Address,City,and Zip �a.� I
W4 V.t. I 3-31 a 13 9 c`z1.4REsu a+�k:e�,3 t ;S 1r agi,F-s c,44gz F. �t (5 �vr ,yy .r
u..... . var`.r3:s UM751
County Parcel Identification No.(PIN) DI C 02i n
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaUlong is sufficient) 22: �,ti n: 1 % r
�' ��.N W
6.Is(are)the well(s): ljermanent or OTemporary Si. e o erti ed ell C acto Date
� signing this form,l hereby certib hat the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or if6o I SA NCAC 02C.0100 or 15A NCAC 02C I0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
t___Geothermal Wells uavin the same ' You may.use the.back of this page to provide additional well construction info
.6.cur veupruueiTyP v. Closed-Loop Geothermal g (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 9 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.)
For multiple wells list all depths if different(example-3Q200'and 2Q100) Submit this GW-1 within 30 days of well completion per the following:
( , 24a. For All Wells: Original form to Division of Water Resources (DWR),
11).Static water level below top of casing: 5® ft. Information Processing Unit,1617,MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" I
.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: Co (inProgram,1636 MSC=Raleigh,NC 27,699-1636
4.
12.Well construction method: a I( 1 6Tt( 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct_push,etc.) couhty environmental health department Of the county where installed
FOR WATER SUPPLY WELLS ONLY: f 24d.For Water Wells producing I over 100,000 GPD:Copy to DWR,CCPCUA
,Ds.iWI Permit Program,1611 MSC,Raleigh',NC 27699-1611
13a.Yield(gpm) I
• 5 Method of test:
13b.Disinfection type: k i-IA Amount: t (6.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resoure s Revised 6-6.2018