GW1--06493_Well Construction - GW1_20231013

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells I
1./W^ellJAContractor I formation:( y/ GGl J / 1"` pies.rjP FRO ATER ZTO ONES DESCRIIPTION
Well Contractor Name t°00 ft /!% ft
2.0367 r ft. >3d ft 517.
NC Well Contractor�Contractor Certification Number •
15.OUTER CASING(for multi cased wells)OR LINER(if ap livable)
/,/r// ,,��//�� II I- , I FROM TO DIAMETER THICKNESS MAW
//
40L/+ /1114[/S W4 I � lib f I -ft. 4./ 62g in. o/Z i/v- _ -
Company Name 16.INNER CASING ORTUBING(geothermal closed400p) : " _ .,
��� FROM
ft. •
TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: Z. . in.
t
List all applicable well constntciionpennits(i.e.Count}:State,Variance etc.) ft ft. in,
3.Well Use(check well use): 17.SCREEN I ;•. -
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft ft.
OAgricultural OMunicipal/Public
ft ft in'
(Heating/Cooling Supply) (Residential Water Supply(single) - -
:
❑IndustriaUCammercial OResidential Water Supply(shared) 1&GROUT -
FROM TO MATERIAL ". EMPLACEMENT M OD&AMOUNT
Ohrigation D ft 2z D: eehoinr'1r° 10U4"
Non-Water Supply Well: ft. ft.
OMonitoring ORecovery
Injection Well: ft. R.
❑Aquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable) - -
FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Storage and Recovery 0 Salinity Barrier ft ft I'
OAquifer Test DStormwater Drainage ft. ft
OExperimental Technology OSubsidence Control 20.DRILLING LOG(attach additional sheets if necessary) - _
OGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,milieu k type,grain size,etc.)
OGeothermal(Heating/Cooling Return) OOther(explain under#21 Remarks) 0 "ZC3 iG / katJ/'1 d
4.Date Well(s)Completed: ( v O " ft 'Y�e c/t
5.Well Location: 'fft. ft.
-F'F�ede f/en-b,-w ( Ll (s fvarli 3i 1,....: ,:-,,---.,;,-----.t •_.•:
Facility/Owner Name Facility ID#(if applicable) ft
ft.
- `,. Sim 64 >' ,i~ I O C i iAl 2023
Physical Address„City,and Zip//r irVG vilC. zii a 21.REMARKS . 'I r r„,-, `•• • _
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if hall bald,ono IaNroos in sufficient) -
3.5o 00 24/ 2 N To. 6.6 W Gar g,zs/'z3
Signature of Certified Well Contractor' Date
6.Is(are)the well(s): all ermanent or []Temporary By signing this form.I hereby certify'that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: OYes or I4No copy of this record has been provided to the well owner.
If this is a repair,fill out!mown well construction information and explain the nature of the 23.Site diagram or additional weU'details:
repair under#21 remarks section or on the back of this form.
/ 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 infection or non water supply wells ONLYwitli the same construction,you can 24.Submittal Instructions:
submit one form ����ir
9.Total well depth below land surface: .() i (ft.) 24a. For All Wells: Submit this,form within 30 days of completion of well
For multiple wells list all depths ifdi erent(trample-3Q2000'and 2®100') construction to the following: ,e
10.Static water level below top of casing: O (ft-) Division of Water Qr ality,Information Processing Unit,
If water level is above casing,use";"
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 /fit (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
/� o •
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 1I/t- /eakiee-„[ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) Ll Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
•
Method of test. A/r' 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) the address(es) above, also submit lone copy of this form within 30 days of
Amount: completion of well construction to the county health department of the county
13b.Disinfection type: where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013