GW1--02034_Well Construction - GW1_20240401

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: j
p5CI e Jr' 5 ;.14i:wATER>ZONES.:. 16.1 ;_ [i':.w;16 r.x.e.'Y' .a;.:e�s Altttsr,;mr ,J;'::
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
Ci lq I iY ' ft. ft,
NC Well Contractor Certification Number
// .15 (liJTERASING(for'.:mulh-cased wells),OR LIlVE'R't(if a Iicah'1e)t'�,'��,�,,.;T&.*f„aEt.��.
c�(/r��� I�tJ)30a1 L(/a 0d!r(/W� FROM TO DIAMETER THICKNESS MATERIAL
J ft. ft. in.
Company Name d'; r�
_t6 NNERCASING"OR`,TUBING.(�eathermaliclosed=l'npp)�'�`" ���`
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS • MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft. 17 0 ft. j/_ in. 51r dV(7 t pr/i
r
C
3.Well Use(check well use): ft, ft. in. O
Water Supply Well: ;17:rSCREENki +l`e",1...i . :'�knr'*Vil:1 s < -r �s :g *`aa"-,- ^. ;:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 10Municipal/Public i 7eft. acoft. Li
inl•• t 679— c t)i LiD � 'V-
Ge thermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in: X• h
dustrial/Commercial OResidential Water Supply(shared) ' s { <
r18:GROUTt:-..rt i ..,. -�iT:..�o'-,A,,�i a�'x3t'a*�,. �,ua�A,�t..+•�A�'€a,:$i.-y
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. 9 0 ft. 6,4 i
W�t
Monitoring ORecovery ft. ft.
Injection Well: •
ft. ft. •
Aquifer Recharge 0Groundwater Remediation
=19::SAND/GRAVEL PACIK(SapphMiibley ''
4.a 'M< s:cAquifer Storage and Recovery �SalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStonnwater Drainage I 6 s ft. 9.0c, ft. C � �
Experimental Technology .11Subsidence Control ft. ft. -
�c
Geothermal(Closed Loop) IDTracer K2o DRIL'li1NG't'sOG(attach addito»liltieeiacheiesstiry}'.t ^.
Geothermal Heatin Coolin Return) (Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
( g/ g
ft. ft.
4.Date Well(s)Completed:'-15.-c94 Well ID# PS 01 6 !% ft- pc oft- L wue .. `
5a.Well Location: ft. ft' •
71h ; F
V �d.Ly ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. APR 2024
153b ia/c_ 3065 9206 ft. ft. ]n::r ;a:;e;t PremweAt the
Physi 1 Address,City and Zip
of •.
?1',;REN''CARKS(°w :.` to 4'i,w;73 '' ,"cc :- _ ti" x
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1 ,
(if well field,one lat/long is sufficient) 22.Certification:
3 a 30l 47 N 76 4 `197 W �� � .—J6—,2�
6.Is(are)the well(s)DPermanent or emporary Signature f Certifie ell Contractor I Date
By sign ng this for n,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or El<o with 15A NCAC 02C.0100 or ISA 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:
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: P bt7 (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"—" 1617 Mail Serviee;Center,Raleigh,NC 27699-1617
11.Borehole diameter: 7 lb (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: L!\ +
,nn (f'/,/ above, also submit one copy of'this form within 30 days of completion of well
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 ServicelCenter,Raleigh,NC 27699-1636
•
13a.Yield(gpm) 77 Method of test: rc.'0Ap 24c. For Water Sunnly& 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: P( 111u Amount: S(y$ , 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