GW1--07083_Well Construction - GW1_20231103

WELL CONSTRUCTION RECORD(GW_1)
;.�.., • .. For Inteinal Use Only:
I.Well Contractor Information:' • , j
• �"seI t ib t rnfzar,.1 14.WATER ZONES li
Well Contractor Nance FROM TO r i DESCRIPTION
NC Well Contractor Certification Number ft. g,
IS.OUTER CASING(forimoltl-cased wells)OR LiNER(if an Roble)Roble)!!�l,AR:+J G Ca.,f.1 e. ' ;11;„=., FROM 1 TO i. DIAMETER THICKNESS MATERIAL
ComppnyName ft. ft.it ' in. I .
���� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: A 3/.g FROM TO • DIAMETER
', List all applicable well constructionpe nits(i.e.U1C.Caney ft. ft. in.
State,Varia:irednce,etc.) THICKNESS MATERIAL •
3.Well Use(check well use): , , � , °'�� °
ft. ft. In.
Water Supply Well: 17.SCREEN '
❑Agriculttual OMtuticipal/Public FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Geothermal(Heating/Cooling Supply) ['Residential (single) ft.
Water Supply ft. ft. in.
, ft. i In❑lndustrial)Commercial OResidential Water Supply(shared)
Olrrigation 18.GROUT ;.
❑Wells>100,000 GPD FROM TO ' MATERIAL'. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. ,
❑Monitoring . . '❑Recovery '
Injection Well: ft.
ft.•
j;
OAquifer Recharge II/ to gdweter Remediation R. R. I
❑Aquifer Storage and Recovery ❑Salinity farrier .19.SAND/GRAVEL PACK(if applicable) .
FROM TO MATERIAL EMPLACEMENT METHOD
❑Agr»fer Test ❑Stormwater Drainage . . n. • ft. {
•
['Experimental Technology ❑Subsidence Control
ft. ft. I; .
❑Geothermal(Closed Loop) DTraoer •, 20.DRILLING LOG(attach additional sheets if necessary) • '
['Geothermal(Heating/Cooling Return) then(explain under#21 Remarks) FROM ft DESCRIPTiON''(mlor,hardness,soil/rock type,grain size,etc.)
tr. ft.
4.Date Well(s)Completed:f O-•t -2 �3 Well ID# / 2 Sft. 774 •tL ,�3 df�e lt�/�� A''�tire/6
5a.Well Location: ,
/ Oivelibur CJ ie .�°�ivtav eL S,Ie eite'b a
C z'�645141'/ rt. R. ; �r, w• &. r t.,i,r' ,
Facility/Owner Name Facility lO0(if applicable) ft. ft. 1 t, � NUV
2®27 Z�eu�e ®• 39�t , .rlrt soNte..v/e 2�.S'V� ft. ft.•
2023
lt;�-
Physical Address,City,and Zip ft. • ft. i 4 -. ' ,-ri"
ON-5/01 It ' 4(3 5113oA 8 J O 21.REMARKS/_ ,
County Parcel Identification No.(PiN) /7't f e'Ce_.....,.2ec.._ f1N//6 ,t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: see� sch e-�-r`c 10 t� �s v str ND iw p��'g .o 1$
(if well field,one lat/loag is sufficient)
22.Certification:
Ski.711/life 6 N '''77. 3g111/0 W 41. 1,/,‘:-„,-AZ,.,/14_ I li - ,-23
6,is(are)the well(s): rmanent or ❑Temporary Signature ofCcnificd Well Contactor Date .
7.is this a repair to an existingwell: l7Yes or By signing lb/sforn,l hereby certify that the well(s)was(were)constructed in accordance with
l�7`JO 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Wet/Constracnon Standards and that a copy
If this is a repair;fill out known sre!1 construction information and explain the mature of the of this record has been provided to the ue/I owner.
repair under tt2/remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DP1 or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I GW 1 is needed. Indicate TOTAL NUMBER of wells '(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
S.7 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (It.)
For multiple wells list all depths if different(example-3@200;and 2@/00� Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: �� (rt.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use +' information Processing Unit,1617'MSC,Raleigh,NC 27699-1617
11.Borehole diameter: C, (In) - 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
41 Program,1.636 MSC;Raleigh,NC 27699-1636
12.Well construction method: i 4. +'t[t�..J1.'iVi . l
(i.e.auger,rotary,cable,,direct push,etc.) 24e.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
' ' county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: •
24d.For Water Wells producing i ver 100,000 GPD:Copy to DWR,CCPCIJA
•
13a.Yield m Permit Program,1611 MSC,Raleigh,NC 27699-1611
(gp ) Method of test:
I
I
13b.Disinfection type: Aniount:
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6•6-20I8