GW1--01876_Well Construction - GW1_20240322

WELL CONSTRUCTION RECORD(GW-1) For Internal Use�rnly:, �1.Well Contractor Information: i� 1'6 k*' __( co a
J ,,/, v eG ,/loll, CI,f// 14.WATER ZONES
Well Contractor Name / FROM TO DESCRIPTION
il
NC Well Contractor Certification Number {)�tg ft D G� ft J!-1 _/y_I'
�j / / /7 �j 1 UTER CASING(for mallti-ccaase(d'w li)„O/R LINER(if sip Iicable)
'// /.e�1�/ 1/-U C Y 4 ( J FROM ft.
TO ft.
DIAMETER in.
THICKNESS MATERIAL
Company Name
16.INNER CASING OR TUBING.(geothermal closed-loop)
2.Well Construction Permit#: (34(eai 0 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(l.e.UIC,County,State,Variance,etc.) d 6- ft. \: .7 ft. 6 in. •/t�7`C',{) , I P //�
3.Well Use(check well use): rt. 7 ft. in17.SC v
Water Supply Well: FROMREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural ['M icipal/Public O ft ft. in.
['Geothermal(Heating/Cooling Supply) Efesidential Water Supply(single) ft. ft. in. '
['Industrial/Commercial ['Residential Water Supply(shared) 1g.GROUT .
I1Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: a ft. 2 ir ft. ^ / 2- ,y 4 g.j Ly- r��
°Monitoring ['Recovery ft 7 ft. �`�(� T(L4`6,r�.�S
Injection Well:
ft. ft.
Aquifer Recharge ['Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
['Aquifer Storage and Recovery •Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
['Aquifer Test ['Stormwater Drainage rt. ft.
['Experimental Technology ['Subsidence Control ft. tt.
QGeothermal(Closed Loop) ['Tracer 20.DRILLING LOG:(attach.additional sheets ifnecessaiy):
ID Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,gain size,etc.)
��� © ft �J ft. O(/G1 /2v(1)
4.Date Well(s)Completed: - ��E- Well ID# / ft �6r eft R15C0 t/J. -0-1�.rfi
5a.Well Location: ft S V r,ft ��4/V1IG
5 v�,alll pvL ft. rt
F,
Facility/Owner Name Facility ID#(if applicable) ft ft 1..-., !%' ,
a
'
5 61. [/)}j i fr 114 c� 7�r 4- it rt. rt. MAN .. r' A
Physicalal Address,re City,and Zip /��7 / • G�4
s9i' eX /9i1� old /SZ� 21.REMARKS
County Parcel Identification No.(PIN) t W�r .YX-:'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
.24% Z5/ /O0 N ssaa t // W 2E� J0� `/"��
h wells ermanent or Tem ora gnature o stifled Well Contractor
6.Is(are)the ()IP [' p ry
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: 211 Yes or EVo with 1SA 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 this form.
23.Site diagram or additional well details:
8.For GeoprobetDPT 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 'S (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example- 100' 2(41100) construction to the following:
10.Static water level below top of casing: !)O (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1J (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
12.Well construction method: R61a.0i construction to the following:
(i.e.auger,rotary,cable,direct push,a c.
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:/ /%/t 24c. For Water Sum&ly&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: Amount: 5 7.45 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