GW1--07099_Well Construction - GW1_20231103

WELL CONSTRUCTION RECORD' GW-fl
I For Internal Use Onl
1.Well Contractor Information: ' j
WIilt��' t��eri
Well Contractor Name • 14•WATER ZONES
FROM TO I IDESCRIPTION
$.76 /� , fr. R.I
NC Well Contractor Certification Number" . ' ft. ft.
�
1./�®� 15.OUTER CASING(for intilti•eased wells)OR LINER(if an [feeble)
I o sc CO. �j FROM I TO II DIAMETER THICKNESS g MATERIAL
Company Name �1 ft. f. I in.
2.Well Construction Permit#: �' Cafe 1 16.INNER CASING OR TUBING(geothermal closed-loop)
List all applicable well construction pe nits(Le.UIC,CounyState,Variance,etc.) FROM TO DIAMETER THICKNESS MATERIAL
ff. it. I in.
3.Well Use(cheek.well use): �'er-s,;74/ �41 W 6`°re..ee
•
ft. ft. , I In.
Water Supply Well: 17.SCREEN I '
•
°Agricultural OMtmicipal/Ptrblic FROM TO DIAMETER SLOT 512E THICKNESS MATERIAL
ft. ft. in.
OGeothernal(Heating/Cooling Supply) °Residential Water Supply(single)
ft. R. 1n
:Dlndustfial/Commercial
❑Residential Water Supply(shared)
❑hrigation la GROUT.
❑Wells>100,000 GPD FROM TO ' !MATERIAL' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
°Monitoring ❑Recovery
Injection Well: ft. ft.
•
•
°Aquifer Recharge {113Groun.divaterRemediation ft. R' -
OAquifer Storage and Recovery OSalinity Barrier .19.SAND/GRAVEL PACK(it applicable) •
FROM TO MATERIAL EMPLACEMENT METHOD
OAquifer Test ,DStormwater Drainage ft, • It.
❑Experimental Technolo •
gY °Subsidence Control • ft. ft
OGeothermal(Closed Loop) OTracer • 20.DRILLING LOG(attach additional sheets If necessary) •
•
❑Geothermal(Heating/Cooling Return) then(explain under#21 Remarks) FROM TO DFSCRIPTtON7coh,.hardness,son/rock type,grain sin,etc.)
,,ryry -� 0 fr. :,S ft. �� ®
4.Date Well(s)Completed:J(1 Well ID# -/ • 2 S tt. y- tt •F-'�° r/J e��a?�f �r-e�� �°A°' 6'�d'�
9./� Q.'4'.-gsty.ap:u c,r ��5��..lor e!L o
5a,Well Location: i _
®,t,eliour Cltilef S°��Er1�3lria� s/e , °cb ��6 Vv99'� rt. ft E .� _
•
Facility/Owner Name Facility i it(if applicable) ' ft• fL
a®t'7 Z vsve B36y, � t�s���J•ilei 5 V� ft. ft. I NOV c L�23 - -
Physical Address.City,and Zip :`�.;
-p ® ft. tr. :n •.•ON-510 LAi I/_�Te/3to y A,sj® 21.REMARKS f i'';i', so, '3 t�i.::
County �tObbi! /D.a,r t
Parcel Identification No.(PIN) - G:Tet/'d•C f't ow eik..)e+,
geed,,ff •
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i eitc le.e1;,-'f-t`a for e a.,+sS¢ra a•.pI e tt e).E
(if well field,one lat/tong is sufficient)
. ��1 N '7 7,. 3 g I I 80 w Zel,„/./14:7. 1f II° --/g--43
®0 22.Certiticati4n:
•
i.6.Is(are)the well(s):• rmanent or OTemporary . Signature of Certified Well Contractor , Date
•
Bysigning Ibis farm,I hereby certij•that the well(s)was(were)constructed in accordance with
7.1s this a repair to an existing well: '°Yes or ®7Vn • ISA NCAC 02C.0100 or ISA NCAC'02C.0200 Well Conshnclion Standards and that a copy
phis is a repult:fill out known Well construction information'and explain the nature ofthe of this record has been provided to ih'nell owner.
repair under it?/remarks section or on the back of this form,: '
23.Site diagram or additional well details: -
3.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional Well construction info
'(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.)
For multiple wells I/ct all depthsifdifjerent(example-3@l00'.nnd 2@100� Submit this GW 1 within 30 days of well completion per the following:
10.Static water level below top of casing: ® '24n. For All Wells:'Original form to Division of Water Resources (DWR),
If water level is above casing,use^+ (f Li information Processing Unit,1617i MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in,) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
�• Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: RO fa:See ly'ie.
(i.e•auger,rotary,cable,direct push etc.) 24c.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 over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gP m) Method of test Permit Program,1611 MSC,Raleigh,NC 27699-1611
:
13b.Disinfection type: Anmount: -
•
•
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201 R
1 i'

. .; •t . ; ; ; ;i I . • ; ;t ;1 ,, .
7.'7,'..,''•...•::::;..i,,''1';-:•.i..::::.‘!•, •:::;.'g'•.• t,i. ,,••••;;.:•..--,;',..1'...:1.,-•.:'•.•-,'.'•:•.',• ;•Y.:.•,-..•••.i,i•,-•;..•••••'...,?" l.",-i..-.....;•••••.- , , ..... .•..........,.........:...,..,..„.,.........,. ..... .
••.;::,•,.::7•.',•:;,1•:•:••.',.:.1....-•''', J....- ---,•-..;,••• •:.: - ..-.:',...,,.-•:•41-.••.,• •:'.!..f,:::;:...•:-• ,::••.-4.:i. 1.‘, . ,• .
• -•-• ••• - - - •••• --• . . . . . .. . ..
• - -•• • • -••- -• •--•• -
'-•:,-'.•;''••••:.-...:- . 1.,4,,,, :,'••••:•••••••:••••;—i •'•;•••:•:.•••••••-• '' r; .: Mutti-Phase tiltraction Weil . •-...-::-;:::::•:•••?:..l.':•••:.,':"." • 1Ievisign.11:.-0.---•-• .. : .•
::.:. ...,•;.:••., ..• .,r. „11.00tAINt114,..-•.,..: ...: ...:•;...... ,::.... , • . , ..:... • • ••••• '••' •:•:" •- "•I tleteiSd date!..5/12/23.. : •-. '••:
,,e-N!;,••••:-•:• • . . •7..T.Z.;:. ',4.•''' '.4 ''''''. . • ' '• • • .' • ;.• - .'- Construction Detail. ...•••••••••:.:•:•::•::. •::::•• ••:,:::.*:. '••••*: - -..-• --- -- :••:j'.• ,
( ; • , .•, .. kOp..,• •:..•., •••..,..„:......:•.: ..:--..••-iroWd by: -.St • . ...---.i.:::....
. , • . , . lldd • Of 11
.... . . „ .
. . ••. ,
. . ,., • . . . .
. .
. . , . ..
... . _
'' .ivi.,i ' ' rl ' 144,1.170, veri Dia. Dote .. ,P.>ii.,,,,:a..7.• . ... .
.•.•
t i
WelilD .•
4,iia , • . , . . , ...
...
• • ,,--- Oversligfit /9
. . I
x i4::vitef • . ' lob II I. .R23-101. ......: ...-.,
,
. • I. : • ..
briller -‘; ._.erMi4*:.... ,1a;,2014 erly . MO:go I; •• Constru.cteri Notes
. . ... .
•z.-
,.. . • . I: • (#11,pOt.ff
. .
' • .. „.-;••.•'erc•.• ..
• loiteitattiMitif . •V"-'44••••-:
. ..„: .. ..
. .... • -fl different)
• •
acitel MO.DialYmtet. .: ,.„. . , Sti6k,Up-fieltifit ,08 : . ..409. ''' •
. I'. :-. • ..
• ,
• .
. • .
, .I; " • .
.:
• . . . •
, •-
. tiroundSurfece 00 . : • •, •!::•:.:: ,. ••• I, . • • .
. :
. . ifirOrikit-;--;-;--- l.V • ‘'.'',..- -
•• , . . -.s.L- ,'
. ' •• - ;V°' • ti I..Angle-06m flOtkoned . 8,''. !.. .
• . . .
- . .
, • .:.,,,,,.,),,,m ,--,,y,V I,. .
1)„..
• -
- • • .w.7,,,J, ,;vi,I.:i . • • , .• • tt•51 041.,rep-40.6Egiend 14'
•. ....:. •......... . .,ii,..5.:.
,. ... .40,0:4v „..,i
. .
: ilMrt.St-i- .-..- . .-. 47,44'"-."'"--Ni.0 • - .•- •- •• - 16'• i.
•' ... Top.of-c crgo ... .
. •' ••• - -• . -. • .,,,k.,,,Z a ....
, • ,
"A4
..
IN* ihe • .
. :'.:;:•••,:•:::. . . . .. 4,1 tin*a VoNe,. ..
.'•. Riser teildiff . ,-2q. li, ;A .... .. . . .
. . -• .. . . ... . .. . , -.. --.,..„,•,.......,..;,-• , . . " .
• Screen-I.diipth - - -65 i ,k1-,,,,'q .i• Batts-df#00:Semd
4e -.- ;.,4-,`.4-,ii Bags - ,4z."11.. 41.:01' :-.• • .
,. . ..„.. • :5?.;s---:'' ', ia"-•;M bong of Cement
• ''' 1! ' 4-. ...,:... ...,.
. . .
. .
•giv..4,....-,.......•le . .!.• .,.. • ,... . ,..• :,........r.. •-
.:2-.! 1 a,.. ••••• ' ,V;;;;; ''fee!;6 ---fmtcr,
4-fixt . 4N05! Ms9- I- . .
.. .
` • . - 44%"--"-".'oA • • 1 • . .
. . . . . . . .. -
• . - ... . . . . ... . ,,-A.,.,.., ...--. *,.,,,1,-..,
. .....t,„:„.. : . . s7.:.....girM ott....:1:.:,...:.•:,,... • !.-,,,,,,,v,yi,,,i',',,,,,:,::-.;•;;;--4,:.•: ."-.-'...1- -amess.5 . .• ,
.'.-s'''•'-i O:AA4±,R E M.ren.m..e.Dl.ei.m er e.r. . .,.
-rTh , 4iliifi ....
•
•
. ,.
-
• - .,-...,.a. P.%,,,- .
•
.:;i4rT4,3:7-40 .!'..:M1'• C......... •04..........*
:51e.:454''''. • Other rimo,
•-.. . . •". . • - ,I,k,-,4 ....* ',,-;‘,4„,, • : .
• : ,-v, ,,,Arx . • .
- , •
SfoiSiie: • ,1.0 Boitmwei Ounct "41' .I •
.. .
Ir.' • . , ,. . . :;gt.:',_?,,„5 ;eg, I_ . '
fC:;:-.:. • - .:' .' ' . ' i'- ''' 1.. I 444..----,* Itg... • . .aotta ,.,
• ,t,,,,..;',V. :;,-.3411 in,o,r-screeil . .81'
•,i,,14,,--,,,y.„.„,,....c.,,,,,z.„,.,
• .
.:-•:-.. !h=•, •A :Ifmai
(.....„44kirtr.•• ..0001'1' :...... *. - . 811., .„.,...... -.$,?..r,t 1
,,:::r,-;.-(:•::':1,';'.. ... -• •isti OfdrOgi-,- 4i,;-
:,,...:,. .. ,.........PPIC•••,...•*,,.. ,:::,•:•...i' : I - • ,,,k1 1
•o 1-6W: .tiy,1:-e .. o . i
e.• • •• •••••:... . . •• ,,,...14.1.:,:. .• • 4ymp.-tengch. , ,.
••,•-. Rotary
.,, Mud• .•• • • .. ..!.1‘t?• •: ;t ,,,.,,,,,.:.
•••,t;40,:., ,;' ;.•,•••••?•••,... ... 1 .
.... • . . ... •.
•-... .. . DOther: , . ... . . . . . :, ,,,.p4 • 14...:.,gOttorn Of Sump . &3.`
,----s
- -- •• -. •:::::•7.--- .,,.,.. i,•4 :h., • . .
,„.... . . . ... ,
: ,. • ••• ...:••.• ..::!..,;11,44 :,•::. ay;.,f3cItom pf frar2hoie
. .
'Y..... : :.''' . ' ' ' ' ' ' . :1 ••••••,.'4!.;'...::•.,::.::::.•:'•• ••. ' - II
• • • ,
:•;,.. •
•••-••.-- •-;••• . . • .. •g..2..,..,'.-,,:-,•---::::: •• • ..- . - . '- • .
••••• ' ' Post-Installation(10(t0 he•Petf.00100:i4hikOffef.inSto11010ti) Pt!)VW.11#00/111.4101: • I, .,
1,,•;:.„,i. . ...,..i.:.,114orflek*ICikte0.#(.0O4 De--.".-cons ti. ted Tim. o ri•*v' Reading 0 PPM
.::• .• - • , bet,th-,to bottom of*011,:tft'61:00z- • :..r!.:•..ri.•• :''• Time 97-IP.- Iteaditix l„6.:(.* . ., , PPM
'SI
'i.••:•', •-,•ijgectitekiiitiO:diO:tiati(OAff,./0 :fh:fin.e/00ey,00:t.iya office Pale: "(lig) ,m-ading: 1: . .,.....' .PPIVI
.,.".:!.' #tonti.efilitij4/40k004grolti*A4ffq0- •' Time: tp:ty
.,, , .,- • Radler,: .1 . - PPM
repeat darlyfinill depth.td,-411itiffs...ift P0, :. . --, ' Time: 116adina: • i • -'• PPM
. .
1 Date ,,,a De*Ii..0:Orput litt-:-66j.:-::: : , : Notes:
1,„:...
. . ...,•••.-:;•:1- ' '•••:'.:'. :-.' ' I
:.•
•. i
- • -•,•.....•:..• , „•. , . ... . . .. ••• •• .. . . ._. , ., • ..• •• I .
•-,k:,. 4,U,A1,14. . •
,----- ,:,..,....;;,.,406,3t • • - ' '. ' . ... . . • - • .
• : . • .,• . - • ::•-z
. .. . .
• • I :At
. ....
... p;.,,,.:-,:•'....., . .• •.. ...•.:---1-:•:::.;':.:'...,..,:-:'...,••••:. .•••••...
:•.:.; •- I- .1 .. ••
-f,;;':-„,...-.,;'. . -61,0,Ag-AUlvi0..;-, ..y.-::: ',-'. -,Y,, .: -.'':.'.. .......-:,. ...:.--..-,,::..,::,!Z.•:.-, :.,:- VO .jal. ..,:A.E'.:.'f,r..i.:.i:.,. ,:rj. %-41 .,'::.'• . ",i,,i,-,,V
, •-. .",,........,f-s'.....nraN •
7.', .•::4--,t.•,, •im,,41,,y4.0t.Aill.,6FAs1;„,:„.,:%.,,,,,,.16‘i,,•wo:E:•••,m,!.,•:.,,,•••:..•,....,,.. :...::...:•...,• .;::q.:•••... 0;;;•,,:.;,,::,,.,.:,-,-.4-..•,,,•,.•,••,•:,,.:::...:::::,•:44m-luo.,pt,:,:n,,,ast.;!„:•,g•...,*:1,:m.,-y•;:.4m.-.•:•.;_:•:•„•-::.::...,•;:-.!,:::,,,,... ,..i::::. ::-.:::;.:-..::.:.,:•.y.,%Ar,;.- ,
',$-='T;fgi,'005. ,"I'kv'e*T'e-krx.tSvP:-'w',',',;§nP,, 4;.,',IoPg.f:RPtgmAA,vtft,'Jt&te.atmg,:o.--Jpevin'Am;2;.,:a.,.;ai,&i,z•au .‹,5:, ,1;F,Jn ,:iwv,J,-;::•.,?,,,
. ., . •
. .: i; • • . ., .
• . • 1 .