GW1--06870_Well Construction - GW1_20231030

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: • !�
1.Well Contractor Information:
(3 l/il.. w--, =1.4.WATER ZONES • '
FROM TO DESCRIPTION
Well Contractor Name
(4q 6--g--G 1Cfo ft. l44eft. 0 kvi
ft. ft.
•
NC Well Contractor Certification Number -15'0OUTER.CASIPG'(for nmtiIti=ctsed'weIisORLINER(if hp licable)-- - -
W k r (A)1 23..cdS T`.^ FRO TO ft. .1c0 f. DIAMETER
THICKNESS MATERIAL
in' 5IN �V
Company Name
:16:INNER CASING ORTUBIN (geothermal closed-loop) , •
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. ' in. -
Water Supply Well: •17:SCREEN
FROM TO DIAMETER SLOT SiZE THICKNESS MATERIAL
*Agricultural °Municipal/Public 0 ft• ft. in.
*Geothermal(Heating/Cooling Supply) n - idential Water Supply(single) ft. ft. ,in.
**Industrial/Commercial °Residential Water Supply(shared) 18.GROUT-
1Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: U ft. .d ft. ford--6- 1 (Oovpd,/ 0 16.5
*Monitoring iiii Recovery ft. ft.
Injection Well:
ft. ft.
®1 Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable) ,
*Aquifer Storage and Recovery (Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
*Aquifer Test InStormwater Drainage ft. ft.
*Experimental Technology DISubsidence Control ft. ft. ! r - -
*Geothermal(Closed Loop) Tracer 20.DRILLING LOG-(attach additional sheets if necessary). - .. . .. .
*Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness sonkrock type amain sloe etc.)ft.
J n ft. ft.
4.Date Well(s) f1��/d Completed: l -j Well ID# ft. ft.
-
Sa.Well Location: • ft. ft. G-. : (. /V- • i:. 7"�
'�^.-a ,
Joe. L.edco‘(d ft. ft. ' O C T
2 0 2023
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ftpis %ftlei Moms GoNe.l._n. .ite lrersa,n LY.. Q(753, `v n r
Physical Address,City,and Zip ft. ft. . `'�"
Nance 21.REMARKS l / , '
County Parcel Identification No.(PIN) L 4� I.,,i',e/- r- __, `per-igi in
Sb.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees: / ,-A`--D
(if well field,one lat/long is sufficient) 22.Certification:
a46oq 3y N -- 7 ,9 3lr‘tf 1s3 W , ke_i /dl(9-/a-3
6.Is(are)the well(s) __ ermanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: fa-Ye-'or Elm, with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy 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:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1}s needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I ) SUBMITTAL INSTRUCTIONS'
9.Total well depth below land surface: /�O (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3©200'and 2d 2(g100) construction to the following:
10.Static water level below top of casing: "' (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617/
11.Borehole diameter: 'Lf (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of tliis form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I
13a.Yield(gpm) /D Method of test: /2( v Vvy 24c.For Water Supply&Injection Wells: In addition to sending the form to
r 5 the address(es) above, also submit one copy of this form within 30 days of
1
13b.Disinfection type: -4-1 14- Amount: �1. 7 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016