GW1--07803_Well Construction - GW1_20231201

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
'..- ost l 1 e.spc55 14♦=,WATER+ZONES i t:.:. , ,(;k,''h+H ,c;,.,..t.E a,.z ,y yet . ,, ..
FROM TO DESCRIPTION:
Well Contractor Name i ft. ft. ! '
ra
t,JIt ft. ft. f
NC Well
ContractorQc Certification Number 15.OUTER CASING(formdlti=cased wells)OR INER(tf ap livable)
` 1 6
.ZV" V b S Vh Pt r I I I fit FROM I TO DIAMETER! ' THICKNESS MATERIAL I
e, ft. ,D,ft. 0 lin. 3?S �Jy
Company Name `;t6.'INNEIZ'CASING OR:TUBING( eotLermahclosed loop)rt`g ' - i
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft, )/ rt. SrIG�
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) /D oV 0 in '3 25
rt. ft. ,in.
3.Well Use(check well use): i
Water Supply Well: FROM TO DIAMETER SLOT SIZE FA/
KNESS MATERIAL
Agricultural Municipal/Public ii66 ft. 9.60 ft. j ///,/�✓n]
,Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft.
�IN
hrdustrial/Commercial OResidential Water Supply(shared) .18.GROUTt': ." -` :r "y -=` •"`' ''
1�,, FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT'
Irrigation 0eu/Cl b ft, t\O ft. �e -
e.
Non-Water Supply Well: O Pour-
Monitoring ORecovery b 144.6 ft. ,C, ft' (m eµ 'Pt,•t,,,t p
Injection Well: ft. rt.
Groundwater Remediation
Aquifer Recharge ty 19.SAND/GRAVEL WCIC:iif appLeabfe)` . } 2'-R174•
q �• _.,.i,b w
Aquifer Storage and Recovery OSalini Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test
EIStonmwater Drainage if ft. ft. i
Experimental Technology DSubsidence Control ft. ft. I '
'Geothermal(Closed Loop) Tracer ,`2li DIII%IANG`I:OG'(attach'ailditionalstitets,iP.necessarY) } a I st ;•
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Retum) nOther(explain under#21 Remarks) ft. ft. F. , �j
_..--7:: ...�...� - '.,: ems.,°.,"..1•
t ! ..
4.Date Well(s)Completed: 1 1•-I f—r�3_ Well ID# —003 ft. ft.
ft. ft. �t_( e) Y ZOZ3
5a.Well Location:
- ft. ft. a
bk./Art
ift: :711:_r^.'nn Pr..-4.'ca..!..,,?l-ive'f
vTf i eel G'�;�t, `'�3
Facility IDS(if applicable) i S,b ft. 21_0 ft. ,/v.54°Ne
Facility'%Oa,ner Name rtUU
ft. ft.
i 3c� 3a(� S7i06 ft. ft.
Physical Address,City,and Zip - _
21''REMARKS C.,!If i`r 1 t ;.:' ?r'r`' YL
ill eCte\SO/f
County Parcel Identification No.(PIN)
i
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
u
-Sias-713y4d " N "7 6, V1-75670 w /i 2,-.23
Signature of ertif d Well Contractor Date
6.Is(are)the well(s)gPermanent or OTemporary t
13r signing this fo in,I hereby cent&that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: IDYes or EtKo with I5A 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:
You may use the back of this page to provide additional well site details or well
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: nt d (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@200'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: d Cli (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: r\� construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,(Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: (f}� 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) �SC0 Method of test: i/w i''lp 24c.For Water Sunni,/& Iniection Wells: In addition to sending the form to
the address(es) above, also subthit'one copy of this form within 30 days of
13h.Disinfection type: I-t+T 1u 1 Amount: S li o S. completion of well construction to the county health department of the county
where constructed.
- ....,. North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016