GW1--06415_Well Construction - GW1_20231009

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple welts
i i
1.Well Contractor Information: -J�
TeFFrev -24.z. e//// /Jis,'..m. I Prt^C< FROM ATERZTO ONES DESCRIPTION
Well Contractor Name ft It 1 /6j �• f i0 �15'11 i
11 & h Z :s� R. ft I I CJ O�
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased wells)OR LINER(if ap livable) - - •
� FROM TO DIAMETER THICKNESS MATERIAL
,C/ e_i JhGC//i S .t''el/ 2riUin zvc. it/ ft- C?Jc' ft 6 /? in. ofa2.,S PG
IN
Company Name 16. NERCASINGORTUBING(geothermal closed-loop) • . - - _
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft ft. in.
List all applicable well construction pencils(i.e.CounIj State.Variance,etc.) ft if, in.
3.Well Use(check well use): 17.SCREEN - -• - .
Water Supply Well: FROM TO . DIAMETER SLOT SIZE THICKNESS MATERIAL
•
❑Agricultural ❑Municipal/Public H. H. in.
❑Geothermal(Heating/Cooling Supply) Iltlilsidential Water Supply(single) ft. ft. in.
❑IndustriaUCottrmercial ❑Residential Water Supply(shared) .1 GROUT .. -. - . . . - . -
FRO�I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 it Q ft 93en nl )404e fed
Non-Water Supply Well: ft. ft.
OMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL-PACK(if applicable)- - . : - .. -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft ft
❑Aquifer Test ❑StormwaterDrainage 'ft ft.
❑Experimental Technology ❑Subsidence Control .
20.DRILLING;LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(rotor,hardness,soWroek type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) t) ft 2 0 ft. Wp d c(L 1
4.Date Well(s)Completed: -'�� ft it /4/�Gym t�/�Jc .
3 r2 ft IMI5 ft , 6,,-..:. /4'Cu e &.TZ
5.Well Location: 9�ft 3 o�. ,._t fl rater Ibe, It
Facility/Owner Name Facility ID#(if applicable) ft. it -
h „i�
Physical Address,City,and Yip ..� ZoL,�
21.REMARKS - iJ
MI c SI ct(,hurl 00,3-. "q I- 33 . ,, OCTr l/
V(
County Parcel Identification No:(PIN) Infor,,,.^,; t.�r;71--
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: "°'
22.
(if well field,one lat/long is sufficient) �-aor
,3 5• Lf 7 6701, N S D i 8/ qO tO2 w 8, .a 3
/� oIC Bed Well Contractor ' Date
6.Is(are)the well(s): 13'Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: Oyes or BIC • copy of this record has been provided to the well owner.
If this is a repair,fill out biro an well construction information and explain the nature of the
repair wider#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
iYou 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 0 v (ft.) 24a. For All Wells: Submit this!form within 30 days of completion of well
For multiple wells list all depths(different(example-3Q200'and 2©1001 construction to the following:
10.Static water level below top of casing: :3 S (ft) -Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+"a 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: ! (in.) 24b.For Infection 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
12.Well construction method: /lD/"r7 •
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program, -
13.FOR WATER SUPPLY WELLS ONLY: • 1636 Mail Service Center,Raleigh,NC 27699-1636
r
13a.Yield(gpm) / O Method of test: f 9/r • 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
A � the address(es) above, also submit'one copy of this form within 30 days of
/T<13b.Disinfection type: /7 T/ Amount ,3 iv/J.) 74S completion of well construction to}the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013