GW1--04367_Well Construction - GW1_20240723

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
i.Well Contractor Information:
S4Art►e y S e.7'z e a. 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
aa 1 gS A 7bft. 71 ft. a►re/+ac_ 3 91,>ti
4(e ft. 39// ft. �i C. Y w
NC Well Contractor Certification Number Q r I y� 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
�CAYYICS ()arty /f�II Pr JJ IIa, L C FROM TO DIAMETER THICKNESS I MATERIALV�
J e ft. /6/ ft. ( in. 5 D 1 T'
Company Name 3 3 I H 6 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State. Varuznee,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.
SC
Water Supply Well: FROM�ENro DIAMETER SLOT SIZE THICKNESS MATERIAL
°Agricultural DMunicipal/Public ft. ft. in.
°Geothermal(Heating/Cooling Supply) ElfResidential Water Supply(single) ft. ft. in.
°Industrial/Commercial °Residential Water Supply(shared) 18.GROUT
11 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. ( ft. 1 1 1.
e o u Po u R
°Monitoring °Recovery ft. ft.
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 DStormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
OGeothermal(Closed Loop) °°Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain we.etc.)
°Geothermal(Heating/Cooling Return) DOther(explain under#2I Remarks)
O ft. /_0 ft. nGGi n /a _
4.Date Well(s)Completed: 51 b`.2AiL11Well no D R. CIO ft tt e.l!a 4, C1K y
5a.Well Location: I30 ft. 13'5 ft. 4-Rl►divtadRaek f- e/tay
Keller Gw,isewh►4e 1.5"3" ft. 350 ft. a Qw 1-1�
Facility/Owner Nan c Facility ID#(if applicable) ft. ft. _
623 Sthvile Spencer nlovniCtin 1\d ft. ft. • w
Physical Address,City,and Zip �1 ft. ft.
Gash-6 n 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Ce • ion•
N W ‘ ei.., ____ ..1-/y-.ZQ2y
6.Is(are)the well(s) Permanent or °Temporary Si of Certified We omractor 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: °Yes or 13No with 1SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information a 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 3'0 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and2Q100') construction to the following:
10.Static water level below top of casing: ".Jr1 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" '1 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: h I/4I (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: �6 � 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: (�I 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 7 Method of test: 16Vd 24c.For Water Supply&Iniection 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: � 1r 7 Amount: O2 completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016