GW1--08128_Well Construction - GW1_20231215

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only: ,
• I.Well Contractor Informatl n'
1.i1 r N 14.WATER ZONES I !
Well Controctarryame •
FROM t TO ' I DESCRIPTION i •
_
NC 'i4-#'6I /6 n, -i0 ft. CO4rse t -14laelf
NC Well Contractor Certification Number IS. R. iSING yr/Ad vbe I�
,,{{ { ` � IS.OUTER ASiNG(for oralti-cased OR LINER f ap lieabte) _
1 4 U r IQ 1 I_J;t I 1%t3- FROM . TO DIAIUE'TER' 1 THICKNESS MATERIAL
r I TT// 11 4. /r5 n' /36 R. Li iln' ahli7 Pvc
Company Name
l, ,�' 16.INNER CASING OR TUBING(geothermal closed-loop)
�
2.Well Construction Permit#: (/(�ry(n 0,95 / O FROM TO - . DIAMETER, THICKNESS MATERIAL _
List all applicable well construction permits(ix.UiC,County.State.Variance.etc.). . fL fL t In.
3.Well Use(check well use): fL It. in.
Water Supply Well: fF7ROS[SCREEN
TO DIAMETER 'SLOT SiZE TIItCKNESS MATERIAL -
Agricultural QMunicipal/Public )�j0 ft. lllo ft. Li in. ,t 0I/o pv6
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) I? n. 7 tt, in.
industrial/Commercial QRcsidcntial Water Supply(shared) IS.GROUT `
irrigation FROM ,TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: /7 ft. 00 ft. �`_"1)�:
Y P .fir�-�iTl � ►l�
Monitoring ❑Recovery n. ft. I
— -- Injection Well:—--— ., — — —
ft. ft.
Aquifer Recharge Groundwater Remediation .. •
19.SAND/GRAVEL PACK-(If applicab]
Aquifer Storage and Recovery 0 Salinity Battier FROM TO MATERIAL EMPLACEMENTMETIIOD
Aquifer Test DStormwater Drainage 113
ft. ,J 10 ft. 611 ,e � rtM.'t-'
I I fir (1
6 a
Experimental Technology 0 Subsidence Control B. ft.
• Geothermal(Closed Loop) .. DTraeer - - - 20.DRILLING LOG(attach additional sheets if necessary) •.
FROM TO DESCRIPTION(color,hardness,soil/rock type.gram size,etc.)
Geothermal(fleeting/Cooling Return) Other(explain under#21 Remarks)
0 ft. /t I. /rip-/
4.Date Well(s),Completed: q a— Well ID# 1 tS ft.. 70 n. (6 Alel 6i e
Sri.Well Location :' 70 ft' • b0 ,tt. 'tam/' •elf-4
tt Vk . . .i� ft.. 'Lib f!., -m 6
K1 V It !C
Facility/OwnerNatne Facility IDx(ifapplicablc) f• ft' .
1-4
-;Physical Address,City,and Zip "- _ - " . - --- ft. ft. ;, , . . , DF;C' 1- p -Lnl 1
i- - 21.11EMARKS
County T Parcel IdentificationNo.(PIN) J
IfliJfi,^: .'nD?�-:�,, m..i, ,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one 1st/long is sufficient) 22.Certifie on:
,..,... Y,,e,..--11 Z.' q-,77-d,3
6.Is(are)the wells) 'ermanent or OTemporary S gnatuse of ificd Well Con ctor Date
,.,,� . By signing form,I hereby cert0 drat the well(s)taws(were)constructed in accordance
7.Is this a repair to an existing welt:• "DYes or I t o . with 1SA NCAC O2C.0100 or 1SA NCAC 01C.0200 Well Construction Standards and that a
Phis is a repair,fill out known well construction information and explain the nature of the copy ofthis record has been provided to the well owner,
repair under 1121 remarks section or on the back of this form. -
.23.Site diagram or additional well details:
8.For Geoprohe/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 of wells construction details. You may also attach additional pages if necessary.
drilled: , • SUB111TTAL INSTRUCTIONS
1
9.Total well depth below land surface: . "7 ) (ft.) 24a. For All Wells: Submit this;form within 30 days of completion of well
For multiple wells list all depths lfdprent(example-3®200'and 101001 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 easing,use"+"- -• µ •
1617 Mall Service Center,Raleigh,NC 27699-1617.-. ------ -'-
tl.Borehole diameter:_ ` -•O (in.) 24b.For[nicction-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
l2.Well construction method: a � f construction to the following: -j1 .•
(i.e.auger,rotary,cable,diieet push,etc.) 1 ..- - - I . , _ .__...._...._._._-
' 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: /II.' /,r 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: N I ea- Amount: completion of well construction to the county health department of the county
where constructed. I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources ' Revised 2-22.2016