GW1--00931_Well Construction - GW1_20240209

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
T'ock WeSpeSS
14:SVATERZONES'^^';�'t)- rF W.M c , zf t 1 ,t z- s y
Well Contractor Name FROM TO DESCRIPTION
ft. ft. J
Lit131 Pt- ft.
NC Well Contractor Certification Numberl ' 15.OUTER CASING(foeiaolti a'se'drwells)AR=I,INER'(ifa lics"tile) , . .
' -- /'/► 1-10Asot/\ tk/ f( l(I f L _ FROM TO DIAMETER THICKNESS MATERIAL
p it y Oft- le? 37 5 S4ce I
Company Name 16.INNER CASING'OR TUBING(geotliermal`cIosed-loop) '
2.Well Construction Permit#:
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Counts;State,Variance,etc.) O ft. I fig ft. n O in. ,') '
. ' J ✓{-c I.
3,Well Use(check well use): ft. ft. f 1e J `
17.SCREEN, : ; eta; . ri t,,. ?;rti; :Z:.;y .
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
,Agricultural *:Municipal/Public ft. ft. in ...___ il.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. I.in. j
Industrial/Commercial 1 OResidential Water Supply(shared) l8 GROUT+. .c-
::3 y, rK4 a w 4$td+:ts�t `j6Yti*i*c..(c^i.
Irrigation tt 4 i1,(/4 . FROM TO MATERIAL EMPL4CEMENT METHOD&AMOUNT
Non-Water Supply Well: O fL 20 it. CerrKCwT t(� 4c
Monitoring - Recovery '1 ft. 6� n. �iPV�MP _
Injection Well: (e ew4 - Y'
ft. ft.
Aquifer Recharge 0Groundwater Remediation
19.:SANDIGRAVEGPACK(•t[,ppti»ble). ,• ',S 1, -.%ita r`. ..:
Aquifer Storage and Recovery DSalinity Barrier FROM • TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology . OSubsidence Control
Geothermal(Closed Loop) OTracer •'2o:DRII:LINOIO INie ch ifldibio'i"ntil eelsit }'?'. `a a`- :
Geothermal(Heating/Cooling Return) (explain 1 Remarks) FROM TO • DESCRIPTION(color.hardness.sal/rock npe•grain size.etc.)
( g/ g Other ex lain under#_ ft. ft.
•
4.Date Well(s)Completed: 1'-,,,25,- ay Well ID# 33°. / ' .' ft. rc. , •
5a.Well Location: - ISS . ft. (51:::$ ft. LI Vie,5444e _
pvlI'i efn .ft. • ft. ' ! , _ @ s�e'ge
Facility/Owner Name . Facility IDk(if applicable) ft. ft. I iz,I. i-l S 3 d lobs '2
7$DG.. ft. ft.
Physical Address,City,and Zip ft. ft.
r 21.REMARKS ? + ,; +Y toi,'farr a-r.ti '--
County Parcel Identification No.(PIN) c
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) i C 22.Certification:
3S.aI700' N 76•' 1 3 wci
i - 04C -a y
6.Is(are)the well(s)�rmanent or Temporary sigmas e of Certified We Contractor Date
- - —- - By signing this form,1 hereby certfJv that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or Etfi4 with I5A NC.4C 02C.0100 or 15.4 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 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: ')..6 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: d (ft.) 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@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 '-'Q ' ' • 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: d.V (in.) 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 .
�Q
12.Well construction method: ITV-kir. construction to the following:
(i.e:auger;roiafy,cable,direct push,etc.)
Division of Water Resources,Underground derground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: (� 1636 Mail Service Center,Raleigh,NC 27699-1636
•
13a.Yield(gpm) ptS t O Method of test: ad N+p 24c.For Water Supply& Iniection Wells: In addition to sending the form to
lTIj i the address(es) above, also submit Ione copy of this form within 30 days of
13b.Disinfection type: i-t Amount: S 144.• 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