GW1--06908_Well Construction - GW1_20231030

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: •
.1.Well Contractor Information:
(JJ�V. JA- lZ Se / `'14.WATER ZONES- _ , --_ -
WellContractor Name FROM TO DESCRIPTION
L!5 7 7 C //S`t. /I co ft. l5 et Pm
ft. ft.
NC Well Contractor Certification Number `.IS:OUTERCASING(for=.multi=eased wens)'OR LINER(trap livable)
Q(n� r �LS ��C ft.
TO DIAMETER THICKNESS MATERIAL
Company Name - (� 0 . 1v 8' ft. if in- S C'H L40 PVC
:16:INNER CASING OR TUBING(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.
I Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft. ft. I.
Industrial/Commercial (°_ Residential Water Supply(shared) 18.GROUT .
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. b g• ft. px.fir R WZcD
Monitoring °Recovery ft. ft.
Injection Well:
ft. ft.
I-- Aquifer Recharge (°_-Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable).
Aquifer Storage and Recovery EDSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test °Stormwater Drainage ft. ft.
Experimental Technology °Subsidence Control ft. ft. ( i
i__ Geothermal(Closed Loop) °Tracer 20.DRILLING.LOG(attach additional sheets if necessary) -.-._ ..._
{-_ Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(rotor,hardness soiVrock type,groin size etc.)
/�++ ft. ft.
4.Date Well(s)Completed: Well ID#A 1 Y1 r13 ft. R.
Sa.Well Location: ft. ft. P; ;— .7--„ft. ft. - ,. - •..,&....� , .1,r I I.-.„,.;
i oseph V11e:1 Ver
Facility/Owner Name Facility ID#(if applicable) ft. ft. 0 C T 3 0 2023
/� ^'f ft. ft.
3QS m\\\ N�\\ 2d �xbnra > �`1S 1`1 1n`^ :'i r ,,., _ � . i
�
r , , ce
Physical Address,City,and Zip ft. ft. f3W,i in OO '
-PPySDr 211.REMARKS.' -
County Parcel Identification No.(PIN) .rAISTPt1'L&D LTkl eta -'• O CU.. • or:
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: M u DO( t.3 A1-ER.
(if well field,one lat/long is sufficient) 22.Certification:
3 (,. 38-) 11o ! ' N - -79 , OT59`l91 W N ctx! 9 -.2A ;3
6.Is(are)the well(s) ermanent or Temporary Signature of CelaA11
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: es or ONo with 15A NCAC 02C.0100 or ISA 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#2I 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 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 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 if different(example-3@200'and 2@l00) construction to the following:
/10.Static water level below top of casing: —5 (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: 6 4, (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
R o7 t 4 above,also submit one copy of this form within 30 days of completion of well
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) 1 Method of test Pu ry ? 24c.For Water Supply&Injection Wells: In addition to sending the form to
1 /(Q the address(es) above, also submit'one copy of this form within 30 days of
13b.Disinfection type: tt Amount: 02" completion of well construction to the county health department of the county
where constructed. I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016