GW1--00362_Well Construction - GW1_20240112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.WellContractor Information: `
t! , k p i tI
1 L 1 () i�. 't+`{P 'a Et� 14.WATER ZONES I
Well ConhaetorNamc FROM TO DFSCRIP7TON
T r (4 c ft. 7 ft. I Gi e n,
NC Well Contractor Certification Number 4—ft. ,,CAI) Jft. f 5t '�1,/1nip.
}} 15--lOUTER CASING(for multi-cased-w )OR LINER(if an cable)
ti�•'GI S I F t�""< lG�k, -�)�\.�``\4y.- `Vl FROM
ft
t TO '� R DIAMETER THICKNESS MATERIAL
Company Name L) ( t//G� 4 in- PVC?
.MANNER CASING OR TUBING ` 4-
(geothermal DICENE s •
-
2.Well Construction Permit#: �'�, A.r(R J FROM TO DIAMETER TJRCK�SS ,may
List all applicable well construction permits(La UIC.County,State,Variance,etc.) fL ft in,
3.Well Use(check well use): ft. 1 ft. in.
Water Supply Well: 17.SCREEN"1�t '
['Agricultural ft FROM TO ( I DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Municipa/Public ft in.
['Geothermal(HeAting/Cooling Supply) [(Residential Water Supply(single)
ft R. I m.
DIndustrial/Commercial 10esidential Water Supply(shared)
Ohrigation 18_GROUT
['Wells>100,000 GPD FROM TO MATERIAL LACEMENI'MErsOD&AMOUNT
Non-Water Supply Well: 0 ft f- cap t ���
II-Monitoring ❑Recovery
Injection Well: tft- 0 rt.F_ yttt �Z �
['Aquifer Recharge OGroundwater Remediation J
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK(if applicable) ,/
PROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage ft ft
['Experimental Technology ['Subsidence Control ft ft.
❑Geothermal(Closed Loop) ['Tracer
20_DRILLING I.OG(actacbadditional sheets if necessary)
['Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIp 11-- (mwr tzar dues•rock type n e etc.)4.Date Well(s)Completed: }0 3 f,� Well ID# - '• 0.
•R f t f ,,,,�. .pp„ �� ey
35
." 5a.Well Location: ... ft �� t "av\i . .. - G - , . •
'Facility/Owner Name Facility 1D#(if applicable) - ft. IL ` k ({,, o
i" 1 , AR k
( ea iatL \,'l�• r7.-e.yi&I'-kSGY\ 3,1S37 ft' • ft. At�.„ �,.„ v a„ Li
•Physical Address,City,and Zip I ) f. ft "t l 1 h }f)24
\t C1 C� 21-REMARKS •
GU
County Parcel Identification No.(PIN) �{� :~ t t �� "�' '..g(.nl
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lar/long is sufficient)
22 C cation
:2io, j C C'9.41 N 1l53', ..k4 S 5_2) W . ;1
f 0t 0 (204 6.Is(are)the well(s): Permanent or ❑Tern ora Si.. -ofC ed a ntractor
PDate
- fly signing this:I her! •certi that the
7.Is this a repair to an ,4 well(s)iwas(were)constructed in accordance with
P existing welt DYes or re I SA 1VCAC 02C.0100 or 15,1 rYCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and/explain the nature of the 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 construction info
construction,only I OW-1 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: Or ( )
For multiple wells list all depths if differed(example-3(a3200'and 1Qa 100� Submit this GW-1 within 30 days of well completion per the following:
) 24a. For All Wells: Original form I
10.Static water level below top of casing- a° to Division of'Water Resources (DWR),
(
If water level is above casing use.' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11_Borehole diameter (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC) '
- - - Program,1636 MSC,Raleigh,NC 27699-1636 - _
12:WelFconstrnction Method: }J A`. (�J
el `�
(ix.auger,rotary,cable,ditectpush,etc.) 24c"For Water Supply and Open-Loop'GeothermalIFetnrn Wells:Copy to the
county environmental health department of the county where installed •
FOR WATER SUPPLY WELLS ONLY: -.
24d.For Water-Wells producing over 100.000 GPD:Copy to DWR,.CCPCUA
13a Yield�•pm) 1 ` Permit Program,1611 MSC,Raleigh,NC 27699-1611
( �Method of test: TR/�_
13b.Disinfection type:J'ii.p ellie'i!-e'Amount ' 2 to . •
,Vj
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6-2018