GW1--00013_Well Construction - GW1_20231218

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: ' •
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'7-1,t WATERZONES.- __- ;'' .„.=
Well Contractor Name FROM TO DESCRIPTION
���� /o ft.
l bc--ft. ".1 ;4Pn
�(/ft. .
NC Well Contractor Certification Number, e FROM AS ` DIAMETER ",-
`tSOUTER CASING(for milh-c8sed wens`)'OH�LINER(if lip-Himmel-- _
J� / I )e �5 i in�, THICKNESS MATERIAL
(/le iLl Q/� 0 ft. Ail ft. d_�y In. 5fo»Z 2/ f i/e-
Company Name IN -(g1.
�+ .`16 INNER CASING_ORTUBING(geothermal dosed-loop) '' , . . _
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2.Well Construction Permit#: 0.7 5 E 0 10 1(0 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in. -
Water Supply Well: 41 SCREEN: _
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
f Agricultural DMunicipal/Public 0 ft. ft. :in.
a Geothermal(Heating/Cooling Supply) riaccesidential Water Supply(single) ft. ft. 1 in.
NIIndustrial/Commercial °Residential Water Supply(shared)
'_:-+Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&�`M OUNT
Non-Water Supply Well: Q ft. 2-9 ft. ./i•o//d/tip14:3/p®ti/•c ti 00/b'g
Ili Monitoring °Recovery ft. ft.
Injection Well: '
ft. ft. ;
;Aquifer Recharge °Groundwater Remediation •• 19.SAND/GRAVEL PACK(if applicable), _ • - `.
*Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
1 Aquifer Test DStormwater Drainage ft. ft.
1+Experimental Technology °Subsidence Control ft. ft.
MP Geothermal(Closed Loop) DTracer "20 DRILLING:'LOG.(attach additional-sheets if.necessary) _
FROM TO DESCRIPTION(color,hardness,soiVrock type,grain size,etc.)
I Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) 0 ft. ft 1 /
4.Date Well(s)Completed: If..- ( I "2ell ID# 6 ft. 2 ge .5 ct- rejeX
5a W ll Location: ft. ft.
ft. ft. .
Facility/Owner Name Facility IN(if applicable) ft. ft. , •"\-I-b,..,`1•._,.(. V ?. -
P HH P II C 2 7 5-3ft. ft. DEC 1 8 70i
Physical Address,City,and Zip ft. ft.14-elg"t it vl.: L�-)
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) ss 22.C • ®don:/�1P//1
36. N o Zg- 33(o3 W J tC� 6 3 o y-4 /2-/I - 20
6.Is(are)the well(s) rmanent or °Temporary Signa of Certified Well Co ct Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or 11"o with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out!mown 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:
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 of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 9 (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: 6 Y (in) 24b.For Infection Wells: In addition to sending the form to the address in 24a
n above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: '41 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resource's,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) 1 Method of test: �®t,tl A �I+'i•"24c.For Water Supply&Inj I tion 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: fi 7 F/ Amount: 15®u Ile(, 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