GW1--00863_Well Construction - GW1_20240205

11111EI VI!
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: ��/�
JCfl1[S(V. G t for U Y
Well Contractor Name FROM TO DESCRIPTION
d`l g- ft. . ft. j. i I o�
NC Well Contractor Certification Number "3-�S'ft. Lit fTft � O�
-15 OUTER•CF SOTING(form alit-cused-wella)OR-LINER(Hap livable) • --•- _
��}�;1 tl , I`/1�y. ,j,,,,( •
1 // FROM TO DIAMETER _THCKNESS I MATERIAL
' e p f-- X1i-1 / i f�`(aliY,•9.11 Lc 11 ft. ft. I in.
Company Name T()r�t i v�
► 1 `/ Y l 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: W Z3 27— (1)1 30 J FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) O ft. C40 ft. / - q� in. �}>n Z j Adt
3.Well Use(check well use): ft. ft. ((! G in.
J{�K
r Supply Well: 17.-SCREEN-={Water
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Nil 1 nicipal/Public ft. ft. .in.
I Geothermal(Heating/Cooling Supply) gi°esidential Water Supply(single) ft. ft. in,
®•Industrial/Commercial DResidential Water Supply(shared)
:r l Irrigation FROM TO MATERIAL 1 EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6, ft- is20 ft. _ -
__ _ " .
*Monitoring 812l'tl� �
® g ORecovery rt. ft. �s�
Injection Well: ally
i�
®Aquifer Recharge DGroundwater Remediation ft. It.
�iAquifer Storage and Recovery Salinity Barrier FRO /GRTO L•PACK(if ERE Lte) :. M -
EMPLACEMENT METHOD
II Aquifer DStormwater Drainage ft- ft.
®'Experimental Technology Di Subsidence Control rt ft.
"Geothermal(Closed Loop) OTracer 20:DRILLING-LOG(attach-additional sheets if necessary)' • -
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
®.Geothermal Meeting/Cooling Return) r Other(explain under#21 Remarks)
r) ft. RDtI• CI au / O�ur ar
4.Date Well(s)Completed:1 a I2Ct 1 Z 1 Well ID# • 9b ft. :' 'ft. /2 „ .L . t/ (
5na.Well Location:
t1111-11tt.f d1:��r�wrt
Nek.- ft rt.
Facility/Owne/Name . )-IOU6}1, 1-kfttef Facility ID#(if applicable) ft. ' ft:
l l S`/ Carhore ha N2ltt, NG � 1(o 1 ft. ' ft. ' 17. �, __,
Physical Address,City,and Zip ft. ft. • k +r a': >,
IV I� t�/) �� :21'.•REMARKS ,�_ -; _ ��i " )• s.,r•' -
1-/a, . It- t-iu z ,CD' t) e024
i
County Parcel Identification No.(PIN)
tnc,:r ,,-s.i n P,.,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I ,,=`' L',;
(if well field,one lat/long is sufficient) mo' /1,�
22.Certification:
. S° 4) t ,g.- 402)11CNl ea?° nt 23allollal4 w
i)/;q12,3
_ _ 6.Is(are)the well(s)Si rmanent or [Temporary - -•: - s' ature of Certified Well Contractor 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: QYes or l with 15A NCAC 02C.0100 or 15A 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 under#21 remarks section or on the back of thisform.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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: . 10 5 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths f different(example-'3@200'curd 2@100')�` construction to the following: -
ilk10.Static water level below top of casing: )b0 (ft.) Division of Water Resources Information ProcessingUnit, -If water level is,above casing,use"+".
•1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: Co • Z ``(in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method CD
above,-also submit one copy of this-form within 30 days of completion of well
g tary, ,cable direct ,
ush etc.) construction to the following: •
(i.e.auger,ro p
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
� , i
�.! `_
13a.Yield(gpm) Method of test: C(Y\��.l l� 24c.For Water Supply&Injection Wells: In addition to sending the form to
I + the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:eh er) Amount: 5 -1-r�h. 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