GW1--03340_Well Construction - GW1_20240603

41-75- L Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:t 1
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1.Wel Co tractor Information: �� l"' ��
� /!/ f I,I 1R WATER ZONES s ! FROM TO DESCRIPTION �/Well Contractor ame [j,g qn• C o n• g y/7'7 „( A/t ii-4_ grc)a
� �-� l_ y DfL J�}V/-�t1JJ 1
NC Well Contractor Certification Numbcr 15.OUTER CASING(for multi-eked ls)OR LINER(if op licable)
Cif (1.4 1- ft./C» //64, FROM ft.
ft. DIAMETER THICKNESS I MATERIAL
K�L( in. Ir 1
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit# 642 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constructionperm s(i.e.U1C,County,Start,Variance,eic. d nit.. P . b 1n. i17 5. f9 /_
ft. in,
3.Well Use(check well use):
1 Water Supply I 7.SCREEN
F FROM TO DIAMETER SLOT SIZE THICKNESS MATF,RIAI.
Agricultural 13Mu icipal/Public ft. ft. in.
DGeothemlal(Heating/Cooling Supply) csidential Water Supply(single) R. ft. in.
['Industrial/Commereial DResidential Water Supply(shared) 18.GROUT
"irrigation FROM TO MATERIAL. � EMPLACEMENT ME t H'OD&AMOUNT
Non-Water Supply Well: Q ft ft.
B<A, /ff f-`i,D,q✓"y 1'1oi)
°Monitoring DRecovcry ft. ft. .-., 6A '
injection Well: D. ft. ?
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. It.
QExperimental Technology DSubsidence Control ft. ft. •
i
Geothermal(Closed Loop) [Tracer 20.DRILLING LOG(attach additional sheets If necessary) ,
FROM TO DESCRIPTION(color,hardness,solUrock t pe,grain size,etc.)
©Geothermal(Heating/Cooling Return) [Other(explain under#21 Remarks) ft.
ft. t
/ O / 7 1 tUe..v 13• /L
4.Date Welt(s)Completed g'q Well iD# / / ) ft• , ft.
,,i k,-df- i2♦CK rnJ 5(
5a.Well Location: 'C� ft. if,
ft. ` 7P � /o
i Ajt/i� v,51 ti S/�/ � n. D��77719 ft. &' -" po q.._114.7 -/ tt"ic•
¢
Facility/Owner Name Facility ID#(if applicable) V �ft•iQ496.ft. &sela j ''I-•+--
1:";)4 a>v� L- Loop It. ft. a.. t i ..,5.
ft ft.Physical Address,City,and Zip '' . _ 2024
fi re-fie/ lei 3 0 D 0 / 21.REMARKS
County Parcel Identification No.(PiN) L°.V.17.2t 3
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Int/long is sufficient) 22.Ce cation: pikm,
-56 /f 3 ,. ..- 7 ir''
,/ �`6'
N g/° S`/. 46`�3" W ? 0-
Signature of Cert Weil Contractor Date
er
6.is(are)the well(s) manent or Temporary � (
By signing this form,i hereby certify that the well(s)was(were)constructed in accordance
7.Is this P repair to an existing well: ©Yes or OK with ISA 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:
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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: l
SUBMITTAL INSTRUCTIONS I
9.Total well depth below land surface: /DOa (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@a 100'and 2@100) construction to the following:
10.Static water level below top of casing: 7° (ft.) Division of Water Resources,Information Processing Unit,
If tinter level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 42 (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:to i!Z r?6Td construction to the following:
(i.c.auger,rotary,cable,direct push, tc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
( rl
13a.Yield(gpm) Method of test:MO-�1X/7 24c. For Water Supply& Iniection Wells: In addition to sending the form to
/,, r // the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:ekt../LJ/i/G Amount: . hY completion of well construction to the county health department of the county
l where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016