GW1--07331_Well Construction - GW1_20231113

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ill R, ±12h S t e-j 14.WATER ZONES i I
Well Contra torName FROM TQO DESCRIPTION
-7 t]M ft. 0 0 ft. 690)'h..
3,5 Lt.I /�0 ft. A 0 0 D- 3G9goh1
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ap ticable)
(- 1 l A 1 p I FROM TO DIAMETER THICKNESS MATERIAL
l I t.n 6 J e tf S l/�/i 1 l " r, . ` I vie . /'f' ft.
/1. rt.
[ t/ in.
Company Name 1 t0 tt7 °©�`1 O P�C'
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: O clop_ (0 00 1 2-7-a 0 a) FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County,State,Variance,etc) ft. ft. 4 in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricglturtl ❑Municipal/Public ft. ft. in.
❑Geothermal(hleating/Cooling Supply) 18fResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑irrigation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACE3IENTMETHOD&AMOUNT
Non-Water Supply Well: D ft. a O ft. Wit ` ii
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. rt.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothctmal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type grain size,etc)
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0 ft. to ft- 1-1-e .1�J i'GC _so/ I
4.Date Well(s)Completed:I!/01/ z 3 Well ID#t5�)P-0OO/g7 Via( (O ft" j S ft. _Bro w vl t 14.-,1 e i?L cl RDc -
SaWellLocation: ,[ fS ft. 2X� H. 6,-,27 V "-et/lit-e-
ft.
t JC( W11 / ft.
Facility/Owner Name Facility MD#.(if applicable) ft. ft
/ YI�L l/C_ R. ft. .1, °,::'1.__.; .V u-
/ t ft. ft •
Physical Address,City,and Zip NOV
`/ y n 23
A 0 _ C D 21.REMARKS • V llV 1 l'
County�b a� Parcel IdentificationNo.(PIN) ' ,7, i-�l.::
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C rtification:
36. 2 It ao N IZ O., 1-E-Z i`i- w ) [2_g72.,3
, II /07
6.1s(are)the well(s):*Permanent or ❑Temporary Sig azure of ern red 11 Coot r Dak
By signing this form,I hereby cerlifi,'that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or *No 15,1 NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a copy
f thus is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remark section or on the back of his form.
23.Site diagram or additional well details:
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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
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: I 24.SUBMITTAL INSTRUCTIONS -
9.Total well depth below land surface; (ft.) Submit this GW-1 within 30 per days of well completionthe following:
For multiple wells list all depths if different(example-3(4200'and 2(a)100') y p
10.Static water level below top of casing:
a O (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-I617
If water level is above casing.use"+"
t
11.Borehole diameter: (in.) 24b.For Injection Wells: Copy to DWR,Undeigiound Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: I/ZD7 2 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) 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
Method of test: ii I Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm)
13b.Disinfection type: 1 G ppAiof lh_ Amount: b Z i
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201 S