GW1--06941_Well Construction - GW1_20231027

WELLY,CONSTRUCTION RECORD(GW-1) For Internal Use Only:
•
1.Well Contractor, formation:
��/ ;•Ci// //1 14::Wz1TEIY'ZQ1 ES ..` i. _ 3z� _x: z.s... : _s ':'
/ • FROM TO DESCRIPTION ,A
Well Contractor Name ft ft.
ft ft 6f 9/ --
NC Well Contractor Certification Number IS:OUTERCASING(for'iriu7h.cased wehs)OR> ,IIH)R fif dp hcz<ble)� ..
i, J��{�J {; ��G V FROM TO D R TTffiCIC ESS) McA/.)ERIAL
(d�/ / �!/ v ft. /04 ft, m J// di / !/C'�
Company Name
q1,qq I 16:INNERRCASING'OR fUUBIN .(geothermalicl`osed loop)>'';`--:K;.; :. ,: �i:i z;:-
2.Well Construction Permit#: � � I �j v 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.SCREEFfaa�:t' K:.a__..._... �. r_._..� ,�*;t�_:s�;�rstu�.< �._
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
M Agricultural DMunicipal/Public 0 ft. ft. in.
!N Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
®Industrial/Commercial li Residential Water Supply(shared) 0: ,,� _ t x s , t: .•..r.
`.d irrigation FROM TO MATERIAL EMPLACE ENT METHOD&AMOUNT'
Non-Water Supply Well: 0 ft. ft. fg.1T1//�� 5 • 5 ./." /� 4
it Monitoring Recovery ft. ft �' �':P`/r�'T �/'vr/
Injection Well: ft. ft.
*Aquifer Recharge ElGroundwater Remediation
f;19.<SAND/GRA'V.ELEACK-(if applicable) z.";.'. ,..ter.,+_1g0:; ::, :``:. ,:•_'
*Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL' EMPLACEMENT METHOD
it Aquifer Test 0Stormwater Drainage ft. ft.
II Experimental Technology D Subsidence Control ft. ft.
illa Geothermal(Closed Loop) QI.I Tracer f20.DRILLINglAriG(attachaddiiiiiiialisheeFAfbeceasary) ...gv ...._.
FRONT TO DESCRIPTION(col hardne soil/rock type,grain size,etc.)
Ti Geothermal(Heating/Cooling Return) fl Other(explain under#21 Remarks) g > //�y�
'�1 ff fL elf q ft. lir I' � VA/^ t��'i`.
4.Date Well(s)Completed! —/9 -5 Well ID# 1 9 ft. / ft. 9i+4v a t�''y`/ l
5a.Well Location: /012 6)b ft. ri0 ft. _5 e!-: qi*F ,2,//7-
%-/l C� �L' )r'!.'. A. (- ft. ft. T ` _ft. ft. ?'tc L.s'k.._:'L,.,L.' is 4."... • .
Facility/Om/ter/Name Facility ID#(if applicable)
,/pU' Y1's7/l M e itz/g/ ft. ft.ft. ft.
0 C T c .2023
Physical Address,City,and ip
Pe-Jell ,2li'-REMARKS t h.,.`£..' .. ,_mot ��+ g '�`"'"'� ', rc^.?,u. •,;Uri
County '~ G:e Ms ���Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(if well field,one lat/long is sufficient) '/ 22.Ce
tification: eiOrni,
• Jf3 { i�'&1 q N ;?4 77/, W .I/7/f#''� ,/ ii, 2'- 3
' Signature of Ce ified Well Contractor ! Date
6.Is(are)the well(s) ermanent or DTemporary
By signing this form,I hereby cent/that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 9Yes or ! 0 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 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: J� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: v y''� (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@2000''and 2@100') 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: lt,/�7 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
- ,-t/ above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: /'�� construction to the following: 1
(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
f i '
13a.Yield(gpm) 2 Method of tesX# LIT/ 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:. / Amount e �A- completion of well construction to the county health department of the county
where constructed.
Form OW-1
North Carolina Department of Environmental_Quality-Division of Water Resources Revised 2-22-2016