GW1--07857_Well Construction - GW1_20231205

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contrabtor Informatio k 1
�I , 14.WATER ZONES
1�U v i1 1 1� �QJ , (j�C S�n FROM TO DESCRIPTION
Well Contractor Name ft. el 5 ft I i
2036 .s. ft 168 ft I ,
NC Well Contractor Certification Number ‘ 15.OUTER CASING(for'multi-cased Wells)GRLINER(if ap licable) . - - •
FROM TO - DIAMETER THICKNESS MATERIAL
DL �Vlv\t%I I VJe&l t\\I nod -I- 1 ft —I1 ft- (9'10 tn. I i2S PVC
Company Name .16.INNERCASING Olt TUBING(geothermal closed400p) _
^ FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 3-1
`q QL ')_ - ft ft. ' in.
List all applicable well construction pennhts(i.e.Countj:State,Variance,etc.)
3.Well Use(check well use): '17.SCREEN .• -
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) ®Residential Water'upply(single) ft ft. . in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT:.. - •
❑Irrigati0n FROM TO ft.
k tMATERIAL EMPLACEMENT OD&AMOUNT
0 ft.Non-Water Supply Well: 20 , tC �"bV' `"^
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft ti•
❑Aquifer Recharge ❑GroundwaterRemediation 19:SAND/GRAVEL.PACK(if applicable) . - • '
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL uurwr- EMPLACEMENT METHOD
(t ft.
❑Aquifer Test ❑Stormwater Drainage ft. it.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary) .
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness, o ck type.grain size,etc.)
❑Geothermal(Heating/Cooling Rez2 �❑Other(explain under#21 Remarks) O ft 'a, ft f- /cp r v e,
ft ft. t
4.Date Wells)Completed:
�3 �0 7 �9ff
cQ/ft •t�ft ro o i t
��
5.Well Location: ` / ft. i ft.
(1tdxo►ncn, Cfart 11 iKLID ft. ft - C;E}V E,[) -
Facility/Owner Name Facility ID#(if applicable)
6`35c) Sl.er1 11 'For-d eci ft ft. DEC 0 5 Z023
Physical Address,City,and Zip
21.REMARKS -
Is;trna,lic n Pr^^sm`' Utz
Z(lwae's 4155-00 1 EW OG
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: )
(if well field.one lat/long is sufficient) 22.Certification: ) -
Signature 3S t 3Cl 02k N ND I Sq 310 W 7 � L �'1�%- — (8 i't"Z 3
of Certified Well Contractor Date
6.Is(are)the well(s): liiPermanent or OTemporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or llNo copy of this record has been provided to the well owner.
If this is a repair,fill out 1..7nown well construction information and explain the nature of the
repair under#21 remark section or od 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
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction lyou can r
submit one form. / 24.Submittal Instructions:
9.Total well depth below land surface: 2 0 0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd fferent(example-3®200'and 2®100) construction to the following: •
i
10.Static water level below top of casing: 3 S (ft) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: h I/E3 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
/
- 12.Well construction method: A 1 -- / construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: J► 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) l Method of test ('t 1�c (
24c.For Water Supply&Geothermal Wells: In addition to sending the form to
'i the address(es) above, also submit'one copy of this form within 30 days of
13b.Disinfection type: I'*'I 1k Amount: \ w14 completion of well construction to the county health department of the county
where constructed.
i
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013