GW1--07794_Well Construction - GW1_20231201

PrinfFortl
WELL COIiTSTR>ITCTION.RECORD(GV�V-g) . • . For Internal Use-Only: " ,. • - �`
- 1.Well Contractor Information:
Gary Thompson :
. .. .. . • _ I�.wAT ZON i ;
Wo11'CotdractorNein • • -. • '' • • .• ' - FROM_•ER:TO ES_ DESCRIPTION••
NC*elt Coidtactor Certification Number • • .•- . . . .
AqI 13.OUTER CASING(forniulttcuedw•ells):OR'LDIERpfap Mbar'. .
�ia DnII,Inc. . . FROM' TO DIAMETER ' . TB1CKNFSS,. MATE
Coin�•°y Na•me•• . ..., • . .
•
•
I .'. • .• • '16.INNER'CASiN13 ORTUBING,(geothermal dosed�loop)
2:Well.Construction Permit#: 3/0%1• • • ' . . _ ' FROM TO : DIAMETER: .. -T ICKNESS.,. 'MATERIAL '
. " List ll applicable uelleoitstruc0on permits(le.Ufa County State Variance,etc.) • ft. ' -ft.- in.
3: ell Use"(check welluse): _
• Water.SnPPi. at,u ' • ' - ." ' f11 SCRE> :
A Ilgncultural' • unicipauPnblio h�ff, RDIAMETERs
. "
LOT SIZE THICKNESS MATERIAL
Geothennal;(Heating,'Cooling Supply)' 11S2Posidenlinl.Water Supply(iing1e) :. ft. ft.. in, .••. -
Incustiial/Commeiofat• • , DResidential Water Supply(share(1) 18.GROUT _.
Irrigation FROM TO ' _ MATERIAL' RMPLACEMFNTMiIrHOD&AMOUNT
Non-Water Supply Well: it.' it•. . e� ..
� : �� : . . �} n�i•F�- 'tau+^ Chi E1='�I�l'dire '
, .- Monitoring . - •. • . . Recov • •• • '
Inj on Weu:
. A fer Recharge . . Groundwater Remediotion ""
19.SAND/GRAVEL'PACK(ifoppilca6le)
Aq afar Storage and Recovery - Sa' i "Barrier. • • 'MATERIAL _ :" .
>�tY . FROM _TO � - EMPLACEMENTMETHOD.
•
Agwfer"Test StomlwaterDrainage' ft —. "
:. :.a erimenIferCCbnology. :" Subsidence Control ' . :it.' ft..: '
ormal(Closed Lapp). : , .;. . 1Yacer.. . 20.DRILLING LOG(attach stidido�l cheats itnecessary)
Geothermal(Iieating/Cooling Return); .IlOthor(explain under#21 Ranarks).11
ft. (�0r•t"mnew.aoWr" �t •�, )
. 1 -`TO DESCRIPTION
4.D>ite Well(s)Completed:"I I-I '•'e? Wen ID# - : t7 .tt. . • _ 4,� ;i;
Se. ell Location: • in',' tt.' - .
. fY't .fi° . •
g4An:•i.)e-a4itleilnall;:z : . .••:• ...• .'. - I a - g4.5 ' .IU &c 1014 ' .�.>
• . • • Facility/OwnerName .FacilitylD#(ifapplicnble) • R: . . •f6- • i t i 'IC.:.41 .;t• .
A. Lt ." _ ..
147 � tiles ' �?f, I,A.7 (is4at�.Sntlpml .JUC. g'71�:`1 _ . . . - '. •�..2023. .. ..
Physical Address,City,and•Zi ( • • • • • R ft. •i -
P �d(•
L, 21.REMARI(S V
County - . • .. .•• PaicelIdentifcation No.(PIN) . - • 1r C ' .'x. i)....,t .
56,Latitude and longitude in dtgreea/mivates/sewnde or decimal degrees ". .- .. ' "
(if we i field,one tatilong is sufficient) : .
• 22:Certiticatlon:
a 4®' (44• 1 tiL(' _•'..N. . 78 0, 14' "g6•1•1'46i'" vir
6.is(are)the wel(s) Permanent .•or Temporary signs oe rtlftedwe ntractec..'. • : Date: - •" .
By signing this fnsn,1 hereby izeigrthat the wel((s)was(were)canstieeted iri accordance
• 1:is.I is a repair to an existing well: DYes or.• o . " ' : ' • " :with 154 NCAC 02C:0100 or!SA NCAC 02e.0200 firell Construction Stc'ndards and.t at a
If this is'a repair,'fill oMk+town well construction in ormation and esphtin the nabire of the •" Copyel�retold hasbeea_pmvided to the well owner. • • - -
repairder 02i remarks sectlon oron'the backofthlsform: .. • ,
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 o.'f wells construction details. You may also attach additional pages ifnecessary,;., .
drilled " :. . . •
}SUBMITTAL INSTRUCTIONS
9.Tolal well depth below land surface:- .411.5 . • ft.' • "
( ) Z4 stauct' i t theWe* wing, this form within 30 days.of wmp. .. of well
For int�ople:wellsJistall depths fjdi�'erent.(example-3 a�i 00'and z®100� conststiction to tha*mowing, _
l- s es0
10.Static water level below top of casingb • :• ,mil©• .•• ' .• (tit.) - Division of Water R rites,Informatlon:Processlag Unit,
If water_level is above Basin&use +" -' '
1617 Mall Service Raleigh,NC 27699-1417- '
11.Borehole diameter "Cp � '.'("u1) -.tab. .- -' �' ? ':..' .' •. .
- .For Inleeflon.Wells: In addition to sending the form to the address`in 24a
above,also submit'one copy of this forth within 30 days of completion of well 12.Well construction method•.' 9.6.627. 1 Ate- - construction to.the following.
(i.e.auger,rotary,cable,direct past,etc.) - , .
Division of Water Resources;Undergronrid Infection Control Program;
FOR WATER SUPPLY WELLS ONLY. " 7 : ' - - 1636 Mall Service;Center,Raleigh,NC27699-1636 -
13n.1lield(gpm) .iO " - Method of test (f ckh+1i;Svtro .24cq For Water Sumily&Infection Wells: In addition to sending-the form to
d - . the addresses)'above, also'subtuit'one'copy of this form Within 30 days of
13b.Disinfection type: d-f TI-1 O /a • Amount: ."•I('e 9i. .- . •completion-of well co nstruction Ito; of the county health department the county •
_ . - - . where'constructed. '
Form GV-1 North Carolina Department of Environmental Quality-Division of Water Reso I s I ' Revised/22-2016
I 1 , n