GW1--06751_Well Construction - GW1_20231023

WELL CONSTRUCTION RECORD (GW-II •For Internal Use Only: 1 ' •
1.Well Contractor'nformation:
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FROM TO DESCRIPTION
Well Contractor Name
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VII
NC Well Contractor Certification Number
'�S.:UO'i`T;R eYSIk(f's(fatiiifiilfC?�c ello'OIeIamof'sjiPlli;ab7��"i,
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tl ft. ft c.. in
Company Name /� < �,
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�� VOJ -0#- t 16 TF `CASiiC 13R;TI#BIAM(geothermal cruse(-1oob:n 3. T. .. ;.. _.`
2.Well Construction Permit#: `� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(t.e.U1C,County,State,Variance,etc.) it. ft. In.
3.Well Use(check well use): ft. ft. In.
watersupplywell 17.SCRBP..N.t_tgn:Viz?1 ,7.�'N? : •V ,.'f. ..`.'.�ati.s'a"!..?` t` .,-.smr,r
FROM TO DIAMETER_ SLOT SIZE THICKNESS V MATERIAL `^
❑Agricultural ❑ unicrpal/Public it, ft. In.
a . k
OGeothermal(Heating/Cooling Supply) esidential Water Supply(single) A ft ft in,
❑Industrial/Commercial ❑Residential Water Supply(shared) z , Ve r >,::,
'�Sits1;2UI1' �..:.5 Y � _ _ n Y,.
❑Irrigation ❑Welts>100,000GPD FROM TO `MATERIAL EMPLACEMENT METHOD&AMOUNT}
Non-Water Supply Well: 0 Ii' 2,0 ft 6Q„V1 Virtl ft ('�V rh
°Monitoring °Recovery it. ft ,J
Injection Well:
ft ft i
°Aquifer Recharge ❑Groundwater Remediation
0$j4 A/GRr1 a (4(00llealiti '-i ._ _.'.a sr_r ...'.V `-. ',. `-,?
❑Aquifer Storage and Recovery °Salinity Barrier ,. FROM TO I MATERIAL_ 1 EMPLACEMENT METHOD
°Aquifer Test ❑Stormwater Drainage It.' —,
°Experimental Technology °Subsidence Control ft. ft. I.
. ,
°Geothermal(Closed Loop) °Tracer ;2Q.6)t11`,0T—G't:C .(ait e}xaddit)'ouafiIiiii ifiieeessni " A r. 1 _k
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION tcolor�bardness,son/rock type,grain size,etc.)
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4.Date Well(s)Completed: 46.. -1 -1'3 Well ID# t of 3 Q •
IQ ft su it. jf'4 G a ck
5a.Well Location: Tri ti41 ft. ' ft. ' l•
Facie�/�7,yt/Owner Name Facility ID#(if applicable) ft ft '. ..'v.�m.4 ,'.,. i,..:.i' 'br' .,.,?.,r'
( is.i.,,, In.
ft. • it. OCT 2, ^023
Physical Address,City,and Zip ft ft.
V L.it i<e, ' I/3
( '1�31 9 s gy I s }..,r .d Lu- 31 r i +RiSVOS t II E;,t '
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if. ii field,one 1st/b oa la sut ici:a)
dd [IJ1 9't�IOII: / , /
6.Is(are)the well(s): Si ermanent or °Temporary r a.:tare of C 'stied 'ell Contractor D
�e •By signing thisfono,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or Lilo ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out(mown well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
• Yn;t may tie.thn harfr of this rage to provide additional well ennctriicti4.n;.ii]fo
p -pr . m nr,,irr ura.WBeu-Luuu VOVuiei mai Wells..havinu.•use seine - -
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks iiox).You may also attach additional pages if necessary.
drilled: 2 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) Submit this GW 1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3©200'and 2©100)
0 a (ft 24a, For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing use"+"
•
11.Borehole diameter: (es (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
s cz�MSC b i t N 274 oo t t l�
12.Well construction method: elk t( roi ``f 24c.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: '24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) AA/
Method of test: C� 10 Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: IA T k Amount: ( 11 16
Form GW-I North Carolina Department oftavironmental Quality-Division of Water Resources Revised 6-6-20iS