GW1--06418_Well Construction - GW1_20231009

I
WELL CONSTRUCTION RECORDIl
For Internal Use ONLY:
This form can be used for single or multiple wells ,.
'1.Well Contractor Information:
/f 4
14`'WATER'7,ONES:. ? ''.l`..::: ".:.;::;.`•c.,:'.::.':.
..... eFFre e-A P"' /ztl an /- /Ce FROM TO DESCRIPTION /�
y Jell Contractor Na -_ - ft.
\, ft.
I , , -1 65 , 3/1'J}
• --- L/&tJ ft. ft
NC Well Contractor Certification Number 15:.OUTER CASING(for'multi=casedddd.:iiells)OR LINER(if licable):'::.; .• ":
/ FROM . TO DIAMETER THICKNESS MATTE'/RIAL-
/a L. lr t5 it a tr/1 /ri�. Z • .t. I ft. /3 oft. 6/g in. p ids / !/ c
Company Name' 46.INNER'CASINGOR:TUBING(geothermal.closed=loop):: ':'``- -'..':`:='°'>,.:•` `
/� FROM• TO DIAMETER THICKNESS MATERIAL
2.Well Construction'Permit#: /00/3 7`7 `I • ft. ft. I in.
List all applicable well construction permits(i.e.County.State.Variance,etc.) '
ft ft. in.
' ,, 3.Well Use(check well use):
17.SCREEN'`•'
Water Supply Well: FROM -TO DIAMETER , SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public .. ft. ft. In.
❑Geothermal(Heating/Cooling Supply) c ❑Residential Water Supply(single) ft. ft. in.
•
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT = :i
//�� FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Hlrrigation ft G� /
Non-Water Supply Well: 0i f
0t 71PJ)�O,1 r 1' p d9Ce re c
ft. ft.
❑Monitoring DRecovery '
Injection Well: - ft. It .
❑Aquifer Recharge ❑Groundwater Remediation =19;SAND/GRAVEL:PACK(if applicable)•: ":':.'.': := _..:.'•.- A..:.;
❑Aquifer Storage and Recovery ❑Salinity:Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft,
❑Experimental Technology OSubsidence Control
20:DRILLINGLOG(attach:additional sheets ifnecessary)'.=t_,;•._ _ '?3":::.: •,::':.r-::'
❑Geothermal(Closed Loop) OTracer • FROM TO ' DESCRIPTION(color,hardness,soil/rock type,gain size,etc.)
❑Geothermal(Heating/Cooling Return) r� ❑0ther(explain under#21 Remarks) 0 ft• a 0 ft' lad C!Qy
�4.Date Well(s)Completed: I� -.2 7— �_3 2 a f, !a.O fc �' i�en,e/ace e 6j
.( ;Well Location: �" �t �'�oft.
v. G�Y �
o Lai imidc `( 'P 9w /3 oft ft SCn• G.
Facility/Owner Name Facili D#(ifJppplicable) 5 a-- .T,
ft ft. iri' �i 'r i
2 06 f'9 A,P ih t. i ch Gc I'G h id . ft it. �+7
Pby iccal Address,City,[and ZipfYi f Q : Q C:T
Z�C�i� Ili iJNr `O lJ �� 0:'0 LUZJ
©��� IRi^r;r' 9'T :7r ^L�.
County J Parcel Identification No.(PIN) Cj>;,:ie: T��"'
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well
'field,one lat/long)is sufficient) Q 76,205 /,
3 •
,� Sr a Ce Well Contractor Date
6.Is(are)the well(s): i/frermanent or ❑Temporary By signing this form.I hereby certify that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Rif 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 of the
repair under#21 remarks section or on the back of this form, 23.Site diagram or additional well details:
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 ONL with the same construction,you can
submit one form. 24.Submittal Instructions:
f
9.Totalwell depth below land surface: . v 5 D (ft.) 24a. For All Wells: Submit this;form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2Q100') construction to the following:'. I '
10.Static water level below top of casing: 3 (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I
11.Borehole diameter: 6/$ (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
"t2.Well construction method: RDT fy construction to the following: . !�
\ ,.e.auger,rotary,cable,direct push,etc.)
_,, Division of Water Quality,Underground Injection Control Program,
P.
13.FOR WATER SUPPLY WELLS ONLY: y� 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) /0 Method of test: / l!' .24c.For Water Supply&Geothermal Wells: 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: /1 / tY) f completion of well construction to;the county health department of the county
/�]� Amount: 3 �Ji where constructed.