GW1--08127_Well Construction - GW1_20231215

r`Pcirit Form --
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: !
f 1.Well Contractor Information:
Joey Thigpen 14.WATER ZONES I . •
WellContmctorName FROM TO DESCRICIIOI4
2631A 3 019 n- 3 yd ft. ..5.e•04
ft. rt.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased*ells)OR LINER Of ap Ucable)
Thigpen Well Drilling FROM TO DIAMETER i THICKNESS MATERIAL
Coco yNama 7/ ft. 50 R. 3 Ij In. L/0 (114-
Qws�o�3 ��/�� /l 16.INNER CASING OR TUBING(geothermal ctosed-loop)
2.Well Construction Permit#: 7 FROM TO , DIAMETER THrcttNEss MATERIAL
List all applicable well construction permits(Lc.UIC,County,State.Variance.eta.) ft. rt. i; In.
3.Well Use(check well use): rt. rt. I; 1n.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public 3&Jft 3Om ? In. D�U i fa a re-
Geothermal(Heating/Cooling Supply) evidential Water Supply(single) Iti ft in.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT I,-
Irrigation FROM TO MATERIAL: EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: a n' ep O it I45-e./-1:
Monitoring:_-- -- -DRecoverry - - - -= ft.-
Injection Well: it. ft.
Aquifer Recharge 0Groundwater Rcmcdiation 19.SAND/GRAVEL PACK([[applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QStormwaterDrainage 2,I7c-it 31/0 ft. is 4
Experimental Technology OSubsidence Control ft. •It. /
Geothermal(Closed Loop) DI'racer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FR�OjM TO DESCRIPTION(cola,hardness,stens&type,grain xis,eta)
V ft / S`- ft. L/t.
4.Date Well(s)Completed://3t 23 Well ID# /5'ft. 63 lJ ft. 5.9-"Q
5a.Well Location: 40 ft 1 re it. u Ay ,.
'ehl / f;�t..fLme ,/ 1 co ft /G d ft Sa - t>7 r ai' {,
Facility/(6wna Name Facility MP(if applicable) /&U ft. -74r ft. C./ ei ,;DEC 1 21%3
9t7�r f c,,-/- NaP-t - !`O/e ✓ ici-e 11 ,gctt. �!3 C4T ft SA,,,`^/-e-- _
Physical Address,City,and Zip 300 it. )ft g "/ C. w tic `..,'(?%,'i�:;a,1.,.;> 1,1;r,
A� 21.REMARKS --
County Parcel Identification No.(PIN)
!
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(if well field,one lat/long is sufficient) 22.Cerd ation:
5 Sit L-f/0 N r7 ),33... w ' cd 4.-- 11-.�a��
6.Is(are)the wells) ermanent or Temporary tare ofC ell Contractor Date
y signing Miriam"hereby cernfy that the uell(s)was(erre)constructed in accordance
7.Is this a repair to an mdsting well: riYes or ieith 154 NCAC 02C.0100 or 15A NCAC.02C.0200 Well Cansmictlon Standards and that a
Ifihis is a repair,Jill out known well construction information and explain the nature of the copy of this record her been provided to the weliowner.
repair under 01 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may usa the back of this page to provide additional well site details or well
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details.You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 W.2 014 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(fd 1 erent(example-3@,200'and 2(g100) construction to the following:
10.Static water level below top of casing: 7 D (ft.) Division of Water Resources,Information Processing Unit,
If rioter level is above casing.use 1617 Mall Service Center,Raleigh,NC 27699-1617
II
11.Borehole diameter: t� (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
. ,f o,,,� above,also submit one copy of this'form within 30 days of completion of well
12.Well construction method: construction to the following: I
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ' Method of test: 4 f Y 24c.For Water Supply&Iniec itm Wells: In addition to sending the form to
/ the address(es) above, also subrnitl one copy of this form within 30 days of
13b.Disinfection type:GA/en.'A L Amount: t 9 Ci 02-- completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016