GW1--06800_Well Construction - GW1_20231023

WELL CONSTRUCTION RECORD
This foam can be used for single or multiple wells For Internal Use ONLY:
1.Well Contractor Information:
te•e\ IN + 74.WATER ZONES. R
eC31W`T1 Ta,t-`CS an FROM TO DF,SCRiPT1ON
Well ContractorNaamee 7c ft to.51 I
�.©e 6b •'•' 1'L /SO ft.
NC Well Contractor Certification Number \ ]i5.OUTER CASING(for multi-cased wens)OR LINER(*Inv(*Invifeeble) • '
t)�.. Pko % FROM TO DIAMVER THICKNESS\ S \iJ c.e 11 \)r%\1 Nf •l 1 ft' 6 aft' e 148 in. O M
Company Name ' P V G
16.INNER CASING ORTUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS ,MATERIAL
2.Well Construction Permit#: • Sq4 5 b-1 • ft. ft. in.
List all applicable well construction penults(Le.Count Slate,Variance.etc.)
it. it. in.
3.Well Use(checkwell use):
., 17.SCREEN • - •
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
OAgricultural OMunicipal/Public ft. in.
❑Geothermal(Heating/Cooling Supply) )!Residential Water Supply(single) ft in.
❑Industrial/Commercial OResidential Water Supply(shared) 18.GROUT ' - •
❑lrrigatioII FROM TO MATERIAL ` EMPLACEMENI1TIOD&AMOUNT
Non-Water Supply Well:
fk '�� fk BeYlCtltsC tJCui'
❑Monitoring ❑Recovery ft. ft ; i
Injection Well; ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(if applicable)• '
❑Aquifer Storage and Recovery p5alinity73arrier FROM TO MATERIAL EMPLACEMENT METHOD
ft ft
❑Aquifer Test ❑StormwaterDrainage
DExpedmental Technology ❑Subsidence Control ft.
❑Geothetmal(Closed Loop) ❑ racer 20.DRILLING LOG(attach'addilonal sheets ifnecessary) •
FROM ' TO - DESCRIPTION(solar.hardness,soft/rack type,grain size,atm)
❑Geothermal(Heating/Cooling Return) COther(explain under#2I Remarks) 0 3t, ft C/Gt
4.Date Well(s)Completed: `2 cd-? . C►TO R' IL el-i �-{" q e
5.Well Location: 6 o ik ft 69�e . 1 e a'.e
•
if r ,t l s . 1 ''ems S ,�
' ' .0 rt. b j t 5 kr(e
l' ` / ft. ft
Facility/owner Name Facility DV(if applicable)
• ft It.
35566 Pte.JJe,- Q� ft. ft. r-Ld
Physical Address,City,and Zip 21.REMARKS
54 an\ 314 SC5 i l l.I :r 2023
County Parcel Identification No.(PIN) I
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: tr:'^
Orwell field,one lat/long is sufficient)
95, "7q 1 N 4,'�r i 2 a 66 W ____Cf _ 7 Z r 3
Siguature of Certified Well ontractor Date
6.Is(are)the well(s): UPermanent or OTemporary By signing this a, orn, I,fhereby certify that the rveII(s)war(were)constructed In accordance
with I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ®'No 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
repair.under 021 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: I construction details. You may also attach additional pages if necessary.
For multiple irtioction or non-water supph'wellsONLY with the same construction,you can
submit preform. 24.Submittal Instructions:
9.Total well depth below land surface: 2 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd((ferent(example-3@200'and 2@100) construction to the following.
10.Static water level below top of casing: 3 0P (ft.) Division of Water Quality,Information Processing Unit,
' If water level Is above casing;use'+" + 1617 Mail Service Ce.nter,Raleigh,NC 27699-1617
Ti.Borehole diameter: b J (in j 24b.For Injection Wells; In addition to sending the form to the address in 24a
flfl above, also submit a copy of this l form within 30 days of completion of well
12.Well construction method: t t v- If R.`r-y• construction to the following
(i.e•auger,rotary,cable,direct push,etc.)
Division of Water Quality,I)I derground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: A 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) J Method of test: k%v- 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
the addresses) above, also submits one copy of this form within 30 days of
13b.Disinfection type: 'S*T q 4 Amount: 1 c..)%1,1TI completion of well construction to the county health department of the county
where constructed.
FennGW--1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013