GW1--00106_Well Construction - GW1_20231228

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well ContractorInformation:
.-- ---'l7 cSV l 1 Ke 5 1€S S : I4. YATEk'zt).NE§ :�,. .<r-:- `..st u.<,. ,,.,2 x•• �t� a.;t:' a .
Well Contractor Name
(/ is
TO DESCRIPTION
Cf U I /� I �� ft. e1 /O ft. L f�c/`�e S�OV
11 11 1 ft. c�17 ft.
NC Well Contractor Certification Number
.I$.OUTER CASING{for,mtili eitIaq'ellsj'ORsLINER'(itli f ahle) x
`� �n/ t f \Svc I ,L I( �/�r - / ; / / - FROM TO DIAMETER THICKNESSKN MATERIALE
V V` ' i-Lc) N/ l U/c G (I.f t2j C.(i� © ft. ((O ft. ?,' j in. I ✓1t6 S f /
Company Name J ` L'e
46:'INNER CASING OR.TURING(geothermal.closed loopy `'
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 6 ft. l 6� ft. c;26 j in. r 3/7 S S4ce 1
3.Well Use(check well use): ft. ft. in.
17.Water Supply Well: FROMN
EEE TO' DIAMETER,• SLOT SIZE HICKNESS MATERIAL
,Agricultural DMunicipal/Public ft. ft. _:-
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. I
Industrial/Commer ial OResidential Water Supply(shared) 18 ROUT. :- '
Irrigation e_14/4-f-G FROM TO MATERIAL EMPLA EMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. a o"ft. ce .1lG� tl ,--"'
Monitoring oRecovery I S n. ��g ft. (e`tc,-J /1'_ IPvvw
Injection Well: 177
_.. _ . .. ft. ft.
Aquifer Recharge 0 Groundwater Remediation
A uifer Storage and RecoverySalini Barrier -4.9 SAND/GRAVEL�PACKtif applicable):.. k;4�' $ iT „ ,`:=r>:..
9 g ty FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStornwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) 0Tracer 26.DRILLING I oG•(attiieWitddittoiiiiii eifil ti ecessa"iy)enL. _ ''"
'Geothennal(Heating/Cooling Return) FROM_ TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
( g/ g nOther(explain under#21 Remarks) ft. rt.
4.Date Well(s)Completed: 1'1.-4-.23 Well ID# 33-OD se- ft. ft.
5a.Well Location: 1 s fa I
i i7 ft. •��5-/ �C
V
�,1 ft. "� ft.
I v\J"e In
PacilityiOwner Name Facility ID#(if applicable)
ft. ft.
is3k) /kA- 30Gs 7160(D �-
!,� of :,, �
Physical Address,City.and Zip` ft. ft. $' P"� i' i9 `
- .-
'Lf+�, C�d-� 21.REMARKS.' . 0G':C.` S.-.:
� Lfl23 .
County Parcel Identification No.(PIN)
• lnT r ?::i�`1 pri^. �-.•,.:;"
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,,,,y b4_,
4.4
• (if well field,one lat/longaf is sufficient) / Q 22.Certification:�l 2 35,E {.11 N �1�. 0�SqD /1iL W • 42"7`g7
d
6.Is(are)the well(s) Permanent or Temporary Signamr of Certified Well ontractor Date
By sign ng this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or EKlo with 15A NCAC 02C.0100 or I SA 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 of this record has been provided to'the well owner. -
repair -
r epair 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: 1
(ft-) 24a. For All Wells: Submit thisl 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: g.9i m.
( ) 24b.For Injection 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
12.Well construction method: l�t7 J�/ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) 4
Division of Water Resources,Underground Injection Control Program,
FOR \'ATER SUPPLY WELLS ONLY: 1636 Mail Service C;e;nter,Raleigh,NC 27699-1636
13a.Yield(gpm) .pcbo Method of test: wchr 24c. For Water Supply& Injection'\Vells: 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: I-I {Z Amount: S I hS. 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 i Revised 2-22-2016