GW1--06750_Well Construction - GW1_20231023

WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only: 'i .
1.Well Contractor Information:
VV SF4;;WA:7'EIaQT3Et!-':„w.o Smigo+'V 5-'�r ..7.0'tAA$``.:,iS. »7
Well Contractor Name FROM TO DESCRIPTION
'1:):1't A f t. 20o 2 ,ft. j I w)
NC Well Contractor Certification Number 1�1$LaTi DER,C}tiSTNfr`(toiIiiiulh-c2sgd`iie-11�Qi L7NER^(i£ap'lic"aiir'e} . r` '7
/- tp� p /� ;,C;
f l f/ vtl Po L W t� u1Y ( 1' FROM TiDIAMETER THICKNESS MATERIAL
IV• N 1 �J 1•1 1.3✓' ft �'� it in.
/10 U fi
Company Name :16:;+NNER OASID(G g12,�T•UBIIYSo
(geoibermal closed)aoP). .w. « '�Y
�j"IW ®q 1 d 3�•- )�a.3 FROM TO DIAMETER THICKNESS MATERIAL x
2.Well Construction Permit#: 111
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. I in.
3.Well Use(check well use): C },ft. ft. in.
Water Supply Well:
xn17:.SCREEPi;i.: 71 S .,tam. i.VR Si..,..'�.'S g_a Y it 2 ..,'./!".:: a
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL~
❑Agricultural unicipal/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) dResidential Water Supply(single) ft. ft. In.
❑Industrial/Commercial ❑Residential Water Supply(shared) t u 5
t$..GRt)�(3', .,, r.: r. � tom. „ . _...�7. -�,.�e . .b4<Mt..'}`S•�':...r.�rtz?�. _c.<5^.. ,a •r4:...'•
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENZ HOD&AMOUNT
Non-Water Supply Well: 0 ft. 10 ft. bell ,til ifei va' 1 y
OMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.S"AND/GRA"VEVPA`CIC Kirlifslicable) 'Kt_'.=f _.kA .y..wr'2,. `..._ a -..
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD _
❑Aquifer Test ❑StormwaterDrainage `n• ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer ,.20:'PRIL'L11staCOG(ttscbrhddstionat sheets if.-iiecessatj .-s;•?; ? +'.,r, >,,,;
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrack type gain size eta)
•
p(g - b ft. a..0 ft. col 4
4.Date Well(s)Completed: - I-13 Well ID# a 0 ft. 10 0 ft• i r1,.....4. Y'b(4,.5a.Well Location: ft. ft.
Lft. ' r,...... : ' - f;.-, Th
Facility/Owner Name Facility ID#(if applicable)
ft. ft. ' ''''''`•..:' .::,i r? :'.,.,,.•,,,,
i 104 (hi Morris rc!Woke Rgie3t ft. ft. OCT 2 2023
Physical Address,City,and Zip ft ft.
W4 Kt, Ziz!1.•.NVARI{.7^.a: Y R ..'NMR PW....l.t C I :-F 44W i,
County Parcel Identification No.(PIN)
5b,Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if welt field,one ladlong iS sufficient)' 22. ti 1C ti n' d
N W --)°�
6.Is(are)the well(s): 4ermanent or ❑Temporary Si e o erti ed all C cto Date
ss signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance with
-
7.Is this a repair to an existing well: ❑Yes or i�No SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under 1121 remarks section or on the back of this form.
23.Site diagram or additional well details:
2 per cteppx.hn.RlPT nr rIneed-T.no`Geothermal'Welk ha,,i„gthesame • You may use the back of this.page to provide additional well construction info
"'- —
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add''See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: I 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: V ®b (ft.) Submit this GW-1 within 30 dayscorn
For multiple wells list all depths if different(example-3@200'and 2®100) of well completion per the following:
10.Static water level below top of casing: 50 (ft.) ,24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"!+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 1D (in.) 24b.For Infection Wells: Copy to DWR,Underground Injection Control(IUC)
try
MSC,Raleigh,NC 27699-1636
12.Well construction method: a I(' 1-6 ('V y 24e.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i,e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 99..'' 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) ° aa Method of test: ��W Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 4 K Amount: ( ,
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018