GW1--00982_Well Construction - GW1_20240209

WELLCONSTRUCTION RECORD(GW-1) For Internal Use Only: `
1.Well Contractor Information:
14.-WATER ZONES ,.. ' .
FROM TO DFSCRIP`tlOA,l_ . . '' -
Well Contractor Name 970 f6 Ti. J�yf_
ft. ft. lef4
A.
-
NC Well Conrtacto Certification Number s.OUTERCASING'(for muIti cased Hells)OR LINER(1f ap licable) ;
FROM TO DI METFR THICKNESS MATERIAL
41T 4 O ft P ILin. cc p,
Company Name 16.INNER CASPNG OR TUBING(geothermal closed-loop)"
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL. -
List all applicable well construction permits(i.e.UIC,Cotrntjt State Variance,etc.) ft ft. In.
3.Well Use(check well use): R. ft: in
Water
Supply WeliiFROM TO DIAMETER .SLOT SIZE THICKNESS ivfATER1AI.
Agricultural ®r licipal/Pubtic /4,. `t. d ft. in. ry�- f llz /ti ,
QGeothermal(Heating/Cooling Supply). denial Water Supply(single) ft. `ffe' ft. in. -�f Sc T
Dlndustrial/Commercial 0Residential Water Supply(shared)
i lrrlgation _ _ FROM TO MATE L - EMPLACEMENT METHOD&.AMOUNT
Nqn-Water Supply'V :. ft. oft. e, / A�,;/ .
Monitoring ®Recovery -. ft. ft. eA)
,IndectionFW.ell �_1- _ _ ... --- =-_ fi _ ,n •-, -— -
Aquifer 0Grot .waterRcmcdiation '' '. "
19::SA,'�DfGRAVEL PACK(if applicable), a . .
,Aquifer Storage•and Recovery W ;alinity Barrier FROM TO vt YrERIAJ,I EMPLACEMENT METROI)
�° "
Aquifer Test ��Stormwater Drainage al"- ,v°`,i' tt. �++� J� ; f
Experimental Technology Subsidence Control
ft. �' ft. t J
Geothermal(Closed Loot. a •-er 20.DRILLLNG LOG(attach additional sheets if necessary) t"•. - ,. "
' FROM TO DESCRIPTION(color hardness sotl/lack t fruit s�et&Il ;+.
Geothermal(Head t., toting Return),,nOther(explain under#21 Remarks) ft. ft. �'�, ,.`� a l4Cd Y
' '
4;Date Wells)Completed:. 914rWell ID# 9 ft: ft. (� ® o ?Q2�
* ft. ft. �"
c 5 ,rir f,n ~,�.. 7
$a.iVell L&litocation: ��p ® � �•7 I r
ft. :`t, ft. , 4. '- -- '�ir':�% --r
�pacili (Dtl'ifa li cable /` ft. ,
Fai ilityithvna Name P'" rY C PP ) t
• t 1 }' J _ I tQ / `�t, /I' .',u�6
Physical Address,City,and Zip
p 21.RErIhRKS
sN
e , .
County Parcel Identification No.(PIN) ' Ca" A
i
Sb.Latitude'and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one latilong.is sufficient) 22.Certificati
N W
6.Is(are)the wet(s) Permanent or Temporary SiguarAe sill led Well Contractor Date
By signing this_farm,I hereby cert05,that the weIlls)was_here)constructed in accordance
-- - ' - -T.IS this a repair to=an:existing'viell:-�-DYes:or- o " - with i.A-.UCAC 02C.0100 or 1"A VC.AC 02C.0200 Well Co0.Mruction Standards and thak[t-;--..-
If this is arepair,fill out brim:well construction informatinu and explain the nature of the cop of this record has been provided to-the well owner- `
repair under.#21,remarks,section taint the hack of this farm, '
23.Site diagram or additional-well details:
8.For Geoprobe/DPT or Closed-Loup Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only,i GW-t 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:". / 0 (ft-) 24a. For All Wells: Submit'this form within•30 days of completion of well
Par multiple wrens list all.depths.ifdillerem(example-3@ 00'and 2(r 100') construction to the following: ;
l0.Static water level below top of casing: 16 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"r' 1617 Mail Service Center,Raleigh,NC 27699=1617 ,
11.Borehole diameter: 2 (in.) 24b.For Iniection 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
12.Well construction (:
•method: M f construction to the following:
(i.e.auger.rotary,cable,direct push.etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm), Method of test: u
24c.,Ft►r JVater SunDly&iafection-\Veils 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: �t Amount: 5 C. . completion of well construction to the county health department of the county
where constructed.
Form(iW-1 North Carolina Department of Environmental Quality-Division of Water Resumes Revised 2-22-2016