GW1--00244_Well Construction - GW1_20240105

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only: .'
1.Well ContraFtor Information: 1
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11.-e.l iV"N %e`� \ac ),� -t1Cw[.`K,sorl 14,WATER ZONES. '
Well Contractor Name FROM TO DESCRIPTION
.Z� ft. R.
''2 U ft. .-20ft. 4460
C
NC Well Contractor Certification Number `
15.OUTER CASING(for multi-cased wells)OR LINER(If ap liable)
Di- M.Sk\1 S W-e--k k Dr-N k‘ t n q FROM ' TO 1 DtAM TER THICKNESS MATERIAL
Company Name J '+1 w7 n 61 Pt, in. t i'1 e,- p\/G
16.INNER.CASING.OR TUBING(geothermal closed-loop) V
2.Well Construction Permit#: 2 g Ci. FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pernilits(Le.U/C,County.State.Variance,etc.) ft. ft. In.
3.Well Use(cheek well use): ft ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public It • n, In.
OGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) g H. in
❑Industrial/Commercial 0 Residential Water Supply(shared) 18.GROUT
❑irrigation D Wells>100,000 GPD • FROM TO MATERIAL ' EMPLACEMENT M THOD&AMOUNT
Non-Water Supply Well: D ft. R.26 l&nert14-e elSrr_c�
❑Monitoring ❑Recovery ft II.
Injection Well;
DAuifer RechargeR. ft.
4 ❑Groundwater Remediation
0/Aquifer Storage and Recovery ❑Salini Barrier 19.SAND/GRAVEL PACK(if applicable)
tyFROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
OExperitnental Technology OSubsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
OGeotht tmal(Heating/Cooling Return) OOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soh/rock type,grahi elm,eta)
0 tt' I D n. bt-uc,.n c.I cY
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4.Date Well(s)Completed: i I 20 23 Well ID# /b it. ft Moe j k .-slcr-e,
Sa.Well Location: ;-i. , n n•
ft.
Feciliy/Q wnerName Facility 1011(if applicable) n• rt. L'• Li kJr r '
4-18'�124 NG �4w'I 8 it: it JA N J z 2024
Physical Address.City,and Zip ft it
64q,n` G /l7 21.REMARKS ltlf,":f7M.g.:t.••,
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'Z s 1 J - �ti
County Parcel Identification No.(PIN) rltr�,�,- .',.,v.:.+9 Uric.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Orwell field,one let/long is sufficient) 22.Certification: � -
35.14$3S1 N �15t 2(54Ln W 3� ., IJ"✓vti _. (113012.3
6.Is(are)the wll(s):*Permanent or DTemporary Slgnatum of Certified Well Coonactor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or SNo 134 NCAC 02C.0100 or 1..14 NCAC 02C.0200 Well Construction Standards and that a copy
finds Is a repair,Jul out knownwell construction information and explain the nature of the of this record has been provided to the well owner.
, repair under 1121 remark 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 construction info
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
i 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: SOb
(ft) Submit this GW-I within 30 da s ofwell completionper the followin
For multiple wells/tat all depths ifdierent(example-3@200'and 2Q100') YP g:
10.Static water level below top of casing: e. r (L) 24a. For Al] Wells: Original form to Division of Water Resources (DWR),
' lfwater level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 f (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control MC)
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�� Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: P' t . u r 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells product's;over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: A- !(" Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 44 1 1- Amount: I p'l frY-k".
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