GW1--00024_Well Construction - GW1_20231218

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
. •
1.Well Contractor lidOrmation:
0144.in .
14:WATER ZONES t
FROM TO DESCRIPTION
Well Contractor Name
3vv-i ,4- ,,c-ft. 3gft o . 7 (Aim
ft. ft.
NC Well Contractor Certification Number 15'.Oul'ER CASING(for multi-cased wel1.4)OR LINER(Rap licabmAl.;)ERIAL" '
FROM TO DIAMETER 15THICICNESS
lAi -rWPte,,,,,,, ;I-7c C . in.
0 ft. 100 ft. Li' MOZ‘ PVC
Company Name
0514)p _coo 50,....z 0 x..„ Fa16.01Z TO DIAMETER THICKNESS MATERIALNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:
' in.
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft.
-
3.Well Use(check well nse): ft. ft. in.', t6;
,, '.1.7.-SCREEN • . • '
Water Supply Well: 4., x 4
-f• -. • ' FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3 ,. icipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) mIResidential Water Supply(single) ft. ft. in.
•.,,.
Industrial/Commercial DIResidential Witet Supply(shared) -18.GROUT
Irrigation -.q .- •••.', - : •FROM TO- - MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ' • ' - •-,-' " s ',..,,-1,-' , 0.z_ft- st, ,ft. 5 rfrio Ii,p 645 tAoe,,,te j/190e
/b.5
Monitoring ORecovery . -!....',,---,_
ft. '' ft. '4 eci- ite...111(.4-‘r pe)kle:d
Injection Well: -
Aquifer Recharge 'OGroundwater RemediatiOi.,
---•!, -' • :•19.SAND/GRAVEL PACK(if applicable) •- -
Aquifer Storage and Recovery OlSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology 1.111'Subsidence Control .-_-...,,..,,,. ft. -,, ft.-
Geothermal(Closed Loop) 01Tracer '
..-7 20.DRILLING LOG(attach additional sheets if necessary)"
4,r
FROM TO DESCRIPTION(color,hardness,soll/rock type,grain size.etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21,Remarks)
ft.
. -. ,--
4.Date Well(s)Completed /V-/3 -2-3Well ID# /19 gC 34, 7.. ft._ cm., f.!.. • . '.,1 ,4,0.
5a.Well Location: Lib ft. _14.00ft.1 :•.-z ,tr. . ,
0411A1 )1/0G4 % ft. ft. 17- -- -=. -._
Facility/Owner Name' Facility ID#(if applicable) ft. ft. ... , .. '-, , ;.,;:.C .,f..- • ' •••••%'''''--
'-- ••••.-. i ;9"k--'• )1
5.53" /01_1/.4-411 rot'. 2e,y4orD 46- ft. ft. nrC
Physica Address,City,and Zip 1757c-I ft. ft. °:. C'1./.(J
21.REM -ARKS ` .' ' • ',.'•,•:-: n
6 rs Del uwc:,L,"1-(3.
, - 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.Ce ' r;tioiti - - '
4 if:- - .
A°I3:1-'i. 0 gg0"N -ig. 50/7g 70 w , -
//-13 -23
6.Is(are)the well(s)Dif(rmanent or EllTemporary ,, .-i Iola of Certified Well Co tractor, Date
By signing this form,I hereby certib,Margie well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or o with ISA NCAC 02C.0100 or ISA 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 oft/us record has been provided to the well owner.
repair under#2I 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: (ft.)474r0.0 ' -
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@l00) construction to the following:
10.Static water level below top of casing: 2-'5 (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: C tg (in.) i
24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: 49 irkr L.' above,also submit one copy of:this form within 30 days of completion of well
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: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) -7 Method of test: 64021...9 A 26$.--)Zfli.For Water Supply&Injection 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: 1-1 I /7-1 Amount: t g ex.."c.eirt 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