GW1--02656_Well Construction - GW1_20240501

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WELL, ONSTRUCTION RECORD r?W 1 `. =Print Form
Eor Internal Use Only:
1.Well Col tractor Information: : _ '
"Y ) !' ) 1..WATE Well Contra or NameR ZONES -- i ( , ?
g� FROM TO DESCRIPTION I_
ik� 4 V� 1 ; ft. ft.
NC Well Co rector Certification Number ft. ft.
r a t ; 1-.OUTER CASING forinulfi cased wells'OR I;INER( f.`..aica6le-
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t ( r •OM ft. �O D, DIAMETER THICKNESS { MATERIAL
Company Na i e
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6 1B,INNE: CASINO
2.Well Co'.truction Permit#: 6` a)--4 b M EothermBfNICKN oo', .
List all appli!-ble well construction permits(i.e.U/C,County.State..Variance,etc.) F'OM ft TO DIAMETER THICKNESS ! MATERIAL
ft. - .in.
3.Well Use check well use): ,
ft. ft. in.
Water Sup{I Well: `
171 SCREEN
-Agricultu!I °Municipal/Public FROM 1O DIAMETER SI.O'rSIZE THICKNESS MATERIAL*Geotherm I(Heating/Cooling Supply) fr• ft• in.
g PP y) esidential Water Supply(single)
III IndustriaUI'ammercial I fr• ft. in.
Residential l titer Supply(shared) !
[rri_ation i
+ IS,GROUT
Non-Water;•apply Well: FROM TO MATERIAL T
Non-Water
_ _ E , ft. 9 + EMPLACEMENT METHOD&AMOUNT
Injection 11: ORecom-ry =- _ — _
Aquifer R� barge ft.
Groundwater Remediation ft. I
)I Aquifer Sti rage and Recovery [Salinity Barrier 19.1SAND/GRAVEti PACIG(if applicpble) ri'�C, 3
�'Aquifer T-�t j FR6M TO MATERIAL
OStormwatera;ainage j ft. ft. EMPLACEM1iENTM1tETHOD
1 Experiment..l Technology °Subsidence iAntrolJ
I Geothermal(Closed Loop) Tracer ft. fr.
Geotherma.(Heating/Cooling Return) *Other(explai'kinder#21 Remarks) FROM f LING:LUG(atta'cfi addttfonal sheets f.necessary)r j
FROM TO DESCRIPTION(color,hardness soil/rock
l 1 � t,� ft• �'1 ft. type,grain size,etc.)
WellAit Well ft. , ti'' �
ID# � fiIQ ft. � 11c�. L���
Sa.Well L bon: t �l 9 f
eJ��""tq , _ �.. . ; g1 ,D.
ct , e I i 9.L l5 ft, / e
Facility/Owner! am
���fi' ft \����)@
Facility ID#Sif applicable) ft. ft.
ft. --t
Physics .Iddre I,City,and Zip r j t 90 ft. e e"{'Ia3,
A F s� 1�1 rk L� '',�91�� 21.REMARKS .. s Y
County Parcelldent flcationNo.(PIN)
Sb.Latitude;nd longitude in degrees/minutes/seconds or decimal degrees: MO;''K`' 'e l' "'"'"'`*)"" '`"''°'
(if well field,o, lat/long is sufficient) (y (�:'g,- ,
4 22,Certification:
I ,
6.Is(are)the I-'ell s 4 �)c l{�ij l� o �A �f�9 j�� _r�
O 'ermanent or Temporary lei alum of crtilied Well Contractor i ! Data
"" -:,Bv s gping/hss/ri,m,"/'hcrebt cei Umt tltc•CT.11 /,was(Nercficonstructed,in aecor'dance
7.Is this a re d air to an existing well Yes or y
1 D ,N ! w'a/ /}s.4 MCA"0?C 0100 ar/SA NCAC.'02C.0200 Well Conshuc/iou"Standards and that a
If/his is a repairi fill out known well construction L frrnuaion and exp ruin the nature of the ' ry q/'this record ord ha.been provided to the well owner'.-
repair under#2!remarks section or on the back of this,/br nr. ! {
23.Site diagram or additional well details:
8.For Geopr;�e/DPT or Closed-Loop Geothermal Wells'raving the same You Iftay use the back of this page to provide additional well site details or well
constructio ,.i ly 1 OW-I is needed. Indicate TOTAL NUMBER ofwells drilled: ! cotlstivction details. You may also attach additional pages if necessary.
9.Total well .I ` SUBMITTAL INSTRUCTIONS
pth below land surface. oft For multiple wel- list all depths ifddereut(cxauip/c-3r r 200'and 3C t00') (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
10.Static wat: level below topof casing: construction to the following:
+ (ft.) Division of Water Resources,Information Processing Unit,
110.Stwater levelicis ,me casing,use
11.Borehole��ameter: j 1617 Mail Service Center,Raleigh,NC 27699-1617
(in.) 24b.For Iniection Wells: In addition to sending the form!to the address in 24a
12.Well cons ction method: l�� (y�ar � above)also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary'cable,direct push,etc.) consttUc[ion to the following:
FOR WATE• SUPPLY WELLS ONLY: I i
Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gp ) t!I
Method of test: 24c.For Water Su v&Iniection Wells: In addition to sending the form to
13b.Disinfecti n type:` � �
I the address(es) above, also submit lone copy of this form within 30 days of
Amount: ,.`)6_)_ completion of well construction to the county health depajrtment of the county where Constructed. •
Form GW-I
North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016