GW1--06395_Well Construction - GW1_20231009

. WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Confr'actor.Information: I,
r^ ✓ 14:WATERZONES-.,:..::: ..' :.;: .
e FF�e/ ���/s Pam/ ��/r'c r� / C P FROM TO DESCRIPTION
Well Contractor Name' ft ft. /P'gj 7 C / ",2 [� 1 ? '
r' -\; �6 0 a ft. ft. ei v .16,
,J••J 1a- ;+C Well Contractor Certification Number .15:OUTER CASING(for=multicass+dwells) LINEN(if-up'Suable).-_.'
V�/]� / // C � / FROM TO DIAMETER THICKNESS MATERIAL
. C. rici /„J Q G/ Vt1iCf,,�/ ��c -1' r ft 53. ft. / r/ iin* a /25 PI,C
Company Name 16.INNER CASING'ORTUBING(geothermal closed-loop)-'•. ' `. ":_: =•
^ r� nr� (J Q FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction'P.ermit#:p(Da e' r v 0 ft. ft. ; in.
' List all applicable well construction permits(Le.Countjt State,Variance,etc.) ft.ft. I in
,, 3.Weil Use(check well use): 17.SCREEN "
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft ft. in.
❑Agricultural . ❑MunicipalPublic
ft. ft. in.❑Geothermal((Heating/Cooling Supply) estdential Water Supply(single) .
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT... = ; .;.. '...:
FROM TO ((MAApTERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 it. 12 ft. ` Ch,r c POD
Non-Water Supply Well:
❑Monitoring ❑Recovery l' ft.
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation -19:SAND/GRAVEL`PACK(if applicable) '.::- : ': . .
❑Aquifer Storage and Recovery OSalinity Barrier / FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft fr.
❑Experimental Technology ❑Subsidence Control
20:DRILLING LOG(attach:additionalsheets if_necessary) --: -:'-:_ > .=.:
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,sail/rocktype,grain size,etc.)
❑Geothermal(Heating/Cooling Return) . ❑Other(explain under#21 Remarks) t, ft- M D ft C
4.Date Well(s)Completed: /•,— r? ! " a J G�oft. 3 ft. �u e /��
5.W I Location: u ,53 ft- 3 O.- 29Lk P C? i s Z- 1
•at ft. ft.(--- . • nnrv4h 'Owe ft
lcility/Owner Name Facility ID#(if applicable) ft. ft ' n�.,.
yea PL cti Rd- �Trou4-md , nc � ry __.--, r,r ,.�,��,
Physical Address,City,and Zip
21.REMARKS..:. . :.: -
o:T 0 9"?02v. . .
aiTolti I 1��51 " tom ci
County Parcel Identification No.(PIN) r.+-1 Lr '
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one 1at/loog is sufficient) /� j
35, (-, ?gg� N SO, 94/5�/ o w ' 2 1 —a3.
c� f Ce led Well Date
6.Is(are)the well(s): Permanent or •❑Temporary By signing this form.I hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that e
7.Is this a repair to an existing well: ❑Yes or li'IQo copy of this record has been provided to the well owner.
. If this is a repair,fill out known well construction information and explain the nature oldie
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
I You may use the back of this page,to provide additional well site details or well
8.Number of wells constructed: 'construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: 3 O 0 (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 1(gi100') construction to the following:
' 10.Static water level below top of casing: 3 -5 (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+� 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: t' /Ca (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this:form within 30 days of completion of well
1d'
12.Well construction method: I. ! r construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
`- Division of Water Quality,Underground'Injection Control Program,
'3.FOR_,WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
t 24c.For Water Supply&Geothe I al Wells: In addition to sending the form to
13a.Yield(gpm) i S Method of test: /*9 1 1^` y the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: ,1 77,1 Amount: completion of well construction tol the county health department of the county
where constructed.