GW1--06491_Well Construction - GW1_20231013

WELL CONSTRUCTION RECORD • For Internal Use ONLY:
This form can be Used for single or multiple wells • r
1.Well Contractor Information:
V t!n u
. `(4v Lffi 3 Gs C16� yM�©n -FROM TO l4:wATErr'zolv := :Es : -: : -l: l.;�:::. '. :;: :,_ - . ..• ...:. ......: .;..• . ', . -:
DESCRIPTION
",ell Contractor Name.' '(ft 2 LI 0 ft.
— 4203 ft. 320 ft. 1
NC Well Contractor Certification Number . o .15:OUTER'CASING(for.-multi-casediWells)OR LINERi(if up licoble)'::,.
��`\� ��\• �``t � DIAM FROM TO R THICKNESS MATERIAL
!�� �
� ft. s rt. L in. `•I T VC.,
Company Name ,t 16.INNER CASING.OR=TUBING'(geothermal closed-Ioo' -
^� �� FROM TO DIAMETER THICKNESS MATERIAL
�•
2.Well Construction Permit#: • , e. ft. ft. I in.
List all applicable well construction permits(i.e.County,State.Variance,etc.) ft. in.
3.Well Use(check well use):
17:SCREEN. ::
Water Supply Well: - FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
(aAgricultural ❑Municipal/Public ir. ft. in.
ft ft in.❑Geothermal((Heating/Cooling Supply) ❑Residential Water Supply(single)
' ❑Industrial/Commercial ❑Residential Water Supply(shared) 18:GROUT --.. `-.
FROM TO MATERIAL EMPLACEMENT METH D&AMOUNT
❑on-Waon O ft ,..Z0 ft. D11� ryz ter.
Non-Water Supply Well: ft. ft. �^-��
❑Monitoring ❑Recovery
Injection Well: ft. ft. '
❑Agwfer Recharge ❑Groundwater Remediation '19:SAND/GRAVEL PACK(if dpplicable)-=. ..'., ::;. `- - -
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft. I
❑Experimental Technology ❑Subsidence Control '
20.DRILLING.LOG(attach:additional sheets if necessary)--.;•"-;:•:.-::-:- "-:::_
OGeothermal(Closed Loop) ❑Tracer FROM . TO I DESCRIPTION(color,hardness,solUrock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) D It (p ft r C_Ic,_
4.Date Well(s)Completed: Z 3 /0 ft -2.0 ft S \ Ave a
2_0 it 4 Delft \VGe S`cAke
Well Location:
/� „
' ft. -ft _
'a-...-) l' eifla e` b`V ft ft - ""` 7+� !'y'•-•r....
Facility/Owner Name Facility ID#(if applicable) ft ft.
Si -l.e W‘i�v 45 Ln . ft. ft . OC T 013
Physical Address,City,and Zip 21.REMARKS" ' :'.-:: -. ' in - ,.i. `� -
,n can O21 03II G;:`•:: : • -C4 ..3 -"
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one latlong is sufficient)
35 ,024Oy N Clvlp'lSbB W 1 113I23
Signature of Certified Well Contractor , Date
6.Is(are)the well(s): lifPermanent or ❑Temporary By signing this form.i hereby certlfr that the well(s)was(were)constructed in accordance
• with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes- or- MNo • 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 Ito provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
I
_ 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: " , 0° (ft.) 24a. For All Wells: Submit this,
,form within 30 days of completion of well
For multiple wells list all depths if di/Jerent(example-3@200'and 2@100) construction to the following:
t
, 10.Static water level below top of c sing: 3 0 (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+' D 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: r B (in.) 24b.For Injection 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
t.Well construction method: ,�-CJ °� • 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
13a.Yield(gpm) 2 0 Method of test: IN ` V" 24c.For Water Supply&Geotherm
al 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: {`T ' Amount: \ V\1...._ S- 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