GW1--00980_Well Construction - GW1_20240209

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WELL CONSTRUCTrON RECORD(G"W-I) For Internal Use Only:
L.Well Conti as. r Infor-matio I
O(XVO v V� 14.WATER ZONES
•Well Co ra•or nine_ fRfUM 'TO DE2tCRIPTI Y
......k
ft. v rt.
NC Well Comet/ireJ 'fie do N tuber �/�J /� 15.OUTER CASING(for multi-cased wells)OR LIFER(If op livable)
1. �1� IW Y 1 t ) M10 I,f^O M. FROM , -_ T DIAMETER ; THICKNESS MATERIAL.
►WN-/�/V 1 ���✓✓✓ ���/1 lr{r,/ s VCI ft. ft. in. t LV `e c
Company Name 16.INNER CASING OR TUBING(geothermal closed-loco
n,n _^ .fit (T P) --
2.Well Construction Permit#: `'�/'(A Y , i/ii/Idtinhn FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constniciion permits(i.e. UIC.County,Slate, i ariance,etc.) ft. ft. in.
3.Well Use(check well use): ft. it. in.
Water Supply Well: 17.SCREEN
itft.M 'TO ' 'DI„MEETER ' SLOT„ZE ' TETCKN FSS ' MATERIALAgriculturalOMunicipal/Publie �i!11 tr In. 11.�1Geothermal(Heating/Cooling Supply) .Residential Water Supply(single) -. et tJ" ft.- In r�flJ 7
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation ,._FROM -TO 1_ TERIAL i E.MPLACE3IENT METHOD&AMOUNT
how-Water Supply Well: - 0 ft. t o ft. J �� �.
Monitoring QRecovcry ft. ft. C"
injection Well: rt. ft.
Aquifer Recharge oundtcater Re; • lotion
19.SAND/GRAVEL PACK Ill applicable)
Aquifer Storage and Recovery �Salin' rricr FROn TO MATE IAI, EMPLACEMENT ME'1'NUD
Aquifer Test ..tormwater Drainage - (1 afar.
Experimental Technology sidence Control ft. ft.
Geothermal(Clos op) QTrac 20.DRILLING LOG(attach additional sheets if necess
FROM TO DESCRIPTION(colo dress,sail rack type,grains@c,eta)
GeoWelm eating/Cooling Rcturu) �]QQOther(ex iu uuder#21 Remarks) it. ft. -73SCR��o!
4.Date Well(s)Completed: I � ` J Well ID# 3 rt. /5"" ft, a 0...'a.mWel/1�Location:-` ,�� ,re: tt /9* ft- ,.4.� r' r----, ' "=L 9
ic-b
-001
ft.
`FacilityiOsvner Name Facility TDN( 'if applicable) 6 y ft. tJ ft. • ..... 4-i-t4 1i A 71114
.a'`6t 1. ..DtA :.gw• V� u/LE '.1 (�
Physical Address,Cily,and''/.ip ft. ft. (MOrif.s=.lin,° t�two
r oa-P t,
21.REMARKS
County Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i
Orwell field,one latllong is sullicien0 22.Certific 1I n:
N W ! /- q
6.Is(are)the well(s) manent or Temporary Sigma. Certified well Contractor Dare -
Per
Br signing this form,1 hereby certj'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or j. o with ISA NCAC 02C.0100 or I SA NCAC.02C.0200 Nell Construction Standards and that a
If this is a repair,fill out known well construction information and explain the iianire oft/te copy of this record has been provided to the well owner.
repair under#21 remarks section or on the hack 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-I 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: eV (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
!or malt/pie wells list all depths ifdii different.(example-3(a 200'and 2(f/00') construction to the following: '
10.Static water level below top of casing: 1f t ,ift.), :Division:of-Water Resources,Information Processing Unit,
If water level is above casing,use"i..; 1617 111ail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (�,�' (in)
24b.For Infection Wells:- Irt addititn to sending-the form to the'address in 24a
12.Well construction method: iyi1.1
above, also submit one copy of this form within 30 days of completion of well
(i.e:augger,rotary:cablecdirect Push.etc:) eR65)4) construction to the following:
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) /5- Method of test: rt,.. 24c. For Water Snooty& injection Wells: 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: ( ,Z,-ZP Amount: I CI completion of well construction to the county health department of the county
where constructed.
Fonn GW-1 North Carolina Department of Environmental Quality-Division-of Water Resources ___ Revised.2 22 2016_ __