GW1--03975_Well Construction - GW1_20240705

WELL CONSTRUCTION RECORD(GW-1)G For Internal Use Only:
1.Well Contractor Information: ,1/p5 7/_I
�'f/-/ S//Lt1//// 14.WATER ZONES.
Well Contractor Name FROM TO D CRD TION •
ft. ft. " 9P 7 t ) 33 5
c)V. " P -// ft. ft. 1/ Il 47'
NC Well�/ll Contractor Certification Number 1S.OUTER.CASING"(for multl-eaied:welLs)"OR TINER'(If ap lleable).
/'// C" f` B{�h` fil//j'� FROM TO DIAMETER THICKNESS MATERIAL'
r m / // 1/ O J �l�t� D ft. �/ ft. in. �0 ,R1 //"
Company Name L
i l l 16.INNER CASIN ,OR TUBINGIgeothermal'elasedaoop).
2.Well Construction Permit#: �'7/(77/ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(l.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural J.M ipal/Public 0 ft. ft. in.
QGeothermal(Heating/Cooling Supply) efesidential Water Supply(single) ft. ft. in.
[Industrial/Commercial [Residential Water Supply(shared) I8 GROUT <'
''Irrigation FROM TO MATERIAL EMPLACEMENT ME't'ROD&AMOUNT
Non-Water Supply Well: fJ ft. 4 ft. ie- 2t ‘,18,1% f jn
Monitoring Recovery ft.
ft. Ir�5 / 7 6�
Injection Well: ffj
ft. ft.
Aquifer Recharge U Groundwater Remediation
19.SAND/GRAVEL`-•PACK(if applicable) '.: .
0Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
El Aquifer Test 0Stormwater Drainage ft ft.
DExperimental Technology DSubsidence Control ft. ft.
DGeothermal(Closed Loop) DTracer 20.DRILLING LOG.(attach.addiHona7aheelsltneceasi _ '. .
(Geothermal(Heating/Coolin Return) n Other(explain under#21 Remarks) FROM To DESCRIPTION(e1oior,hJ, ).av�k true grate>i�etc.)4.Date Well(s)Completed: ��? Well ID# 7 ft. // ft- /r y 4A1 - ,
5�a Well Loca�tionn: " 6/ sI P ft' CG tWi 1 q/Z/a/55
L' i tie/"/ n/i r- Dfly t,iy /�/t ft. ft. )
Facility/Owner Name Facility 1D#(if applicable) ft ft. r-• _ ,
L D ,)omen/ dr 13 1nf/T ft. ft. , % 1/4. " k or E Li,r4
Physical Address,City,and Zip ft. ft.y� l, )i
0 5. Oc
G //✓777� 21.REI4IARKS-
County Parcel Identification No.(PIN)
CPAC.r ICE
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) yQ/ 7 22.Cj, n.rtificatio L�/�d��
_ 35) t-? 8/r�17 N ( / i a07P i 74 W / , �%�L�' {%1� 4 -,,7, -d i/
6.Is(are)the well(s) ermanent or DTemporary Signature of ed Well Contractor Date
� 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: DYes or Di 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#2I 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 neceacary,
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: t;;P (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: 34 (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: "/ (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
J`� �/ �, f,/ above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: / . 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) [O Method of tes/ / i T 24c. For Water Suuoly&Infection Wells: In addition to sending the form to
y / the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: �/ // Amount Ul 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