GW1--06906_Well Construction - GW1_20231030

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
1.Well Contractor Information: • "
rio ija--(2. 0 14:WATER zoNFs- i,....
Well Contractor Name FROM TO DESCRIPTION
W 6'P 6-C —G 69�—?fit. Oft. o,�j g pkt
ft. ft. `
NC Well Contractor Certification Number /� ',15:OUTER CASING(for'multi-eised wellsj:OR LINER(ifap Ilcable)` -
1 1 r -_ f _ i i C_Ae Ib p j y r' FROM
B ft.
TO
�,fy R DIAMETER THICKNESS MATERIAL
MATERIAL
Company Name C� V✓ IJ�/� C! '0L l in. `�� 'r"af►� r l/ v
p Y :16.INNER CASING OR'TUBIN�(geothermal closed-1oop)-
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 f,,:; p.." o 0 ft• ft. in.
il Geothermal(Heating/Cooling Supply) dential Water Supply(single) ft. ft. in.
NI Industrial/Commercial DResidential Water Supply(shared) 18.GROUT •
t ;!Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. PO
ft. n l Pc e / g6 O AS
*1Monitoring e'•ecovery ft. O ft. ('
Injection Well:
ft. ft.
*Aquifer Recharge ;__.Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable):.
fif tAquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Nil Aquifer Test °Storrrwater Drainage ft. ft.
$-Experimental Technology °Subsidence Control ft. ft. f
It Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary) -
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
1:Geothermal(Heating/Coolingp/Returrn) n Other(explain under#21 Remarks) R R.
4.Date Well(s)Completed: `1 I I t /�}'�)2 'Well DM ft. ft. .
5a.Well Location: ft. ft. 1 k-,,,g.-.f '$�> __,_i
J —CA -'n --)OPLe.P ft. ft. o C T ? Q'
20
23
Facility/Owner Name Facility 1D#(if applicable) ft. ft.
2'r(f 0 c . „v.,- Q (}' / 60( ft. ft. ti:,;r ir=t.^l ?�Ur
�i
rt:�
ft. ft.
Physical Address,City,and Zip
v'
eg�-,Q A 21.REMARKS f �1/�()
County Parcel Identification No.(PIN) 1 -I("�i l 't•"QJ C `l _!
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r,g7s�✓A kin
(if well field,one lat/long is sufficient) 22.Certification:
3( 1x)C•/ 7c�6"
/ N-7U.•D0K6fs2Q W /D/:9-Ag
6.Is(are)the well(s) enent 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: Fle es or °No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out blown 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 GV�-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: l SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: a: 0 (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 2@100') construction to the following: i
10.Static water level below top of casing: 9'' ^ (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
! ' I
11.Borehole diameter. of (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
_ ,1I above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: (1`� construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
• Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) () Method of test: O 24c.For Water Supply&Injection Wells: In addition to sending the form to
/ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: •4—44 Amount: b-/AAa_- 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