GW1--06230_Well Construction - GW1_20230925

1; .
•
1.
WELL CONSTRUCTION RECO {GW-11 For Internal Use Only:
1.Well a r•Ilfo tlo a ° L. •
t.!
•14.WATER ZONES I.
Welf Cos for sine FROM TO DESCRIPTION 1
' NC Well Connecter Certification Number
•
� ,A 15.OUTER CASING(f•
or multi-eased wells)OR LINER ff ap liable)
'W �JV+ FROM - [TO DIAMmR THICKNESS Qp MATERIAL
. .
. .
Company Name �'�'ll�j • J
f I ' •
1
2.Well Construction Permit#: �/lj. p 16.INNER CASING OR TUBING(geothermal etoied-loop) •
PROM TO DIAMETER THICKNESS MATERIAL
. List all applicable well construction permits(l a COG Comry,State,Variance,eta) 1..! to G m 7/d Ko !T.3.Well Use(check well use): ft. ft. be. 771 U7
Water Supply Well: .k7:SCREEN .
°Agricultural ?ROM TO DIAMETER SLOT SIZE THICKNESS MATERIALOMunicipal/Public „
•
°Geothermal(Heating/Cooling Supply) idential Water Supply(single) ,''
l7lndustrial/Commeroinl ClResidential'Water Supply(eh • ft. ft 1'• in*
18.GROUT t;
•
°Irrigation • [Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENTME/HOD ticAmoma
- Non-Water Supply Well: V __ fl/'
l7Monitoring °Recove - f t. �•• f /Y�Lr - w t A;, i'� _
Injection Well: ry, ft. Torti4ii
°Aquifer Recharge . . OGroundwaterRemediation ft.. IL
°Aquifer Storage and Recovery °Salinity Barrier -19.SAND/GRAVEL PACK(if applicable) • •
PROM ' TO MATERIAL EMPLACEMENT METHOD •
. ' OStomwater Drainage ' ft. ft.
.i'. .
°Aquifer Test
- . °Experimental Technology, ❑Subsidence_Control ft fZ
. °Geothermal(Closed Loop) " • °Tracer.
20.DRILLING LOG(attach additional sheets if necessary)
ss
'. ❑Geothermal(Heating/CoolingReturn)' °Other PROM . TO .. , DISCRR'TION(c.br,harde
(explain tinder#21 Remedrs) . aa, Nnek type,eraia sire,eta)
•
•
4. i�t..
Date Well(s)Completed: O 'Ly-Z3 Well ID# ft
c
s�eP �, e.J.bo�-, •
' So.Well Location: n ?2- �siq IA
.St°�l eWiCG� ••• 1 4 ' rs . • ,•
f
Facility/Otvn�Name ` a') -�s`Ga h v ,
Facility• ID6(if applicable) ft.
`I�1 (�r�s�23rlt (.V 0 -.s�or,w or w -m ft ; � �
Physical Address,city,led Zip I v CS 0 M 'n�v' `` i ! '�'F
• L,,.: .Zl.REMARKS!VGI1CV � J�Py2O2. .COunty a Parcel ldentifieation No.(PIN) •
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ' ' ' 1nfor
,(if well Said,one lat/loug is sufficient) 'r1Se'e.1 p„
- ' '. 12-'
•, s 22.Certific i• ' C'9r*J '» 3a:'� iJr,>
-3L . 1 �' I . N - $l i- '.a� , 3�-" ..
W.
• ,.' q-15-23 6.Is(are)the well(s): CIXtrmanent or °Temporary a A SO s Signature b C ontrictor _ Date
7.Is this a repair to an existing well: °Yes or No l5.4 NCAC 02C:0I00 o 15AN C 02C.0200(We Cp ruction Sconsttandards ds and a copy
If this is a repair,fill out Anewn well construction information and rplain the nature of the of this record has beenprovidedto the well owner.'repair under il21 reniarkssection or on the hack ofthisform
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 Construction info
•
construction,only 1,GW 1 is needed. Indicate TOTAL NUMBER of wells. (add'See Over'in Rfniarks Box).You may also attach additional pages if necessary.
drilled: • -
24.SUBMITTAL INSTRUCTIONS
• ' ' 9.Total well depth below land surface: •3,22s. • (ft.) ,
•
For mrrltlple wells list oUduipths((different(example-3Q200'and 2QI00) Submit this GW 1 within 301 days of well completion per the following:
10.Static water level below top of casing. • :Z ft 24a. For All Wells: Original form.to Division of Water Resources (DWR),',�
Ifwater level►s above casing:eve"+"`, ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter. 1�7f .1.
.(in.) 24b.For Infection Wellb:Copy to DWR,Underground Injection Control(IUC) ,
z Program, MSC,Raleigh,INC 27699-1636
12.Welt construction method: J \b-laI
(i.e:auge,'rotary,cable,d¢ectpuslt,eta) - 24c.For Water Suppby and Open-Loop Geothermal Return Wells:Copy to the
. county environmental health department of the county where installed
•-• FOR WATER SUPPLY WELLS ONLY: : •
24d.For Water Wells prod:i ing over 100,000 GPD:Copy to DWR,CCPCUA
•
13a.Yield(gpm)' . 16 Method of test: Gu t,..' Permit Program,1611 MSC,Raleigh,NC 27699-1611
‘1.13b.Disinfection type:- L r-' Amount. 0t ' ..
- '
.
•
•
Form OW-1 -15 North Carolina Depmumrent ofEnvironmenta( null "
Q tY-Division of Water Resources "Revised 6.6 2018