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Home My WebLink AboutGW1--04595_Well Construction - GW1_20240731 • Print Form WELL CONSTRLC'TION RECORD (GW-1) [For internal l.,seOn!v: ` 1.Wel Contractor Information: r lit l • t 5 -a 14.WATER ZONES Well Controctcr\arc FROM TO DFS.'RIP JO` 3 7 l� ,R 0 ft. L; ft- I.u,,�1 NC Well Contract r Certification Number fv fr. 1 Iron.l/ D• i Jake( __4 ( � -• I 15.OU iER CASING(for multi-ease.,wells)OR LINER(if ap table• _ J ny V{ ) lit ,; c �4•e 1✓'✓ r// t 7 \ FR.LHOM TO DIA:rtE ER IHIC VESS MA 'RIAL 1 / h-^ IN l C 1 ( / GJ J ft, ft. in. ' / H Company Name I ' C i • 1 16 INNER CASING OR TUBING(ge thermal cl -loop) 1 FROM I TO THICKNESS MATERIAL �� 2.Well Construction Permit#: DIAMETER 1 Lot all applicable well construction permits(i.e. WC,County.1 tare. Variance,etc.) it, it. fl in. i -. �--'- - 3.Well Use(check well use): ft. i ft. 1 in. Water Supply Well: I 7.SCREEN _ ' FROM ! TO I DIAM-TER + SLOT SIZE ; THICKNESS MATERIa_l A gricultural �MunicipaitPublic f L rt. (C G ft. • In. , 1 S g c lit` 0 0,61 aGeothermal(HeaungiCouling Supply) Resider,::al Water Supply(single) rt , It. is I DIndustrial/Commercial DRer:?•ntia!Water Supply(shared) 1 18.GROUT ntnn'station FROM I TO I MATERIAL ! EMPLACEMENT_METHOD&AMOUNT Non-Water Supply Well: '1 ft. fri+hut:P Or N i 3 Monitoring �F.ecovery I R.rt. l •- rt. Injection Well: i 8 ft. ft.Aquifer Recharge Groundwater Remediation i 19.SAND/GRAVEL PACK(if applicable) Aquifer Storage and Recovery Salinity Barrier ; FROM TO MATERIAL EMPLACEMENT METHOD Aquifer Test OStormwater Drainage .7(-- R. f eft• I 5 �� j j G`c,�� Experimental Technology QSubsidence Control R. f ft. Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary) i , FROM TO DFSCRIP'rION(<obr,hardness,soil/ruck type,grain site,ei:.i Geothermal I Heating Cooling Return) [Other(explain under r+2. Remarks) 1 I. f7 u H. i rt. �p SC,/ --� 4.Date Wells)Completed: /- ll - !" Well IDd_ 7 ft. c ft. ! c- a` -- Sa.W Loca lion: 2 C ft. L ft. 1 ( rtf _ • . !/e . 4i✓rn tt ft. . 1; ft. ` /4 --4 Faciaty Owner\amc F Dn a applicable i G l' ft. r tl7 ft. S qe`L -..c air f 17: I } I --'t„1 4. V im e/ ' f' ,c r y Arr rL ft. i ;... Phys� Address.C l:., and Zip 4.- ft. ft. �I L 3 l ZOL� / ,-:"f 21.REMARKS __ »r r^y+K 94 Count. ,�✓, Parcel idenuticanon No.,PINi ►��:F '" 5b.Latitude and longitude in degrees/minutes.'seconds or decimal degrees: _ • u'well field.one fat long is>vintien!' 22.Cerj{(Icatioti: - 1/4/ _ ,/ . 6.is,are)the well(s) 'Permanent or Temporary Si; titre of Certified Well Cont for Date Bs signing this fair.I hereby certify that the well(s)was(were)constructed in accordan.e 7.is this a repair to an existing well: QYes or t .No with!SA,SCA( 72C 0/00 or 15A.VCAC 02C 02W)Well Construction Standards and:hit a Phis is a repair.till out known sell construction inJormarin rp:ain the nature of the cape at-this record Oar heen provided to rk, well owner repair under#2/remarks section or an the back of this Jar.. 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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary drt lied: y / SUBMITTAL INSTRUCTIONS 9.Total well depth below land surface: e( tee, M.) 24a. For All Wells: Submit this form within 3f1 days of completion of well For multiple wells list all depths if different'example-/)i;200' ad 2.if•''70' construction to the following: teA 41 10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit, il..uu•r/cvet ire above costing use '- 1617 Mail Service Center.Raleigh.NC 27699-1617 11.Borehole diameter: -1.' (in.) 24b. For Iniection Wells: in addition to sending the form to th;a,idress in 2-la 12.Well construction method: et above, also submit one copy of this formwithin 30 days of completion of well 14' r V construction:o the following. i i c.auger.rotary.aaole.due::n'ss:�,::, • / Division of Water Resources,Underground Injection Control Program, FOP.WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh.NC 27699-1636 13a.Yielr!(gpm; 7-4 C' Method of test: i) r 24c. For Water Supply& Injection Wells: In addition to sending:I:e form to �4J-,e P' j � the address(es) above, also submit one copy of this form within i0 days of 13b.Disinfection tvpe: 1i e Amount: completion of well construction to the county health department of the county where constructed. Farm G,A'-: North Carolina^,anur•ment of F.ay.romncntal Quality-Division of Water Rcsourc., Rcvised:22-2016