GW1--04925_Well Construction - GW1_20240816

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Wellelll Contractor formation:
. b A///e7G 14.WATER ZONES
FROM TO DESCRIPTION
Well Cc[or Name
4�O c lcil• _cG ft. 3 d frig
NC ell Contractor Certification Number ( L le, 15.0ER CASINGT (for malti-ca welt)OR LINERTRICKNESS(if a cable)
AL
f METE sed j r� p� ��eRI
�UT
iL
Co ny Name (Yi/
I14 a 010 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.U1C,County,State.Variance,etc.) ft. _ ft. in.
3.Well Use(check well use): R. ft. is
Water Supply 17.SCREEN
PP Y Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
°Agricultural unicipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft, ft, in.
Industrial/Commercial Residential Water Supply(shared) 18 GROUT
Irrigation FROM TO
TO MATERIAL EMPLACEMENT METHOD&AMOUNT
v Non-Water Supply Well: ft•
: ft• )0,17t-r/ye 7 '
Monitoring Recovery ft.
ft.
Injection Well:
Injection ft,
Aquifer Recharge °Groundwater Remediation 19.SAND/GRAVEL PACK(If applicable)Aquifer Storage and Recovery Salinity Barrier FROM TO )MATERIAL EMPLACEMENT, METHOD
Aquifer Test °Stormwater Drainage ft' ft' Ir� i C tii�
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
(Heating/Cooling Other ex lain under#21 Remarks) FROM TO DESCRIPTION(enter,hardens,sell/rock type,grain size,etc)
GeothermalReturn)1'/� (explain Q ft. 4G ft. keel c lG V
4.Date Well(s)Completed: gel °f'7 Well ID# IC,- ft. T ft. C-/''C^'''e
5a.Well Location: '1v ft. 6 kS ft G�.... 1,.
Yl.'-eri6it 3v ( `-1157 ft. ft.
Facility/Owner)Name J Facility ID#(if applicable) ft. ft. - _
0 53 / tUl/60R (p1/'t C't/ ft. ft. ., . • •l. . i f i.. )
Physical Address,City,and Zip
ft. ft. AUG 1 ( 2024
6 6S 7 -/) 3 S6). o 5a ye 21.REMARKS irefc,:, .,,:,r,1 , ,
County Parcel Identification No.(PIN) ()'/t'C.: t,-G
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: ?` s '- A
3sgC7 yo N 4 l f 70 W 4-7e_4_.�ei) ire if:, /a -.2y
Signatu�of Certified Well Contractor
6.Is(are)the wells) Permanent or °Temporary
By signing this form,I hereby certify that the wall(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or ONO with ISA NCAC 02C.0100 or 1 SA 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 co 'of this record has been provided to the well owner.
repair under#11 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: (� (R.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 1 /00) construction to the following:
10.Static water level below top of casing: C' (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
f
11.Borehole diameter: 11)1 t0- (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: ,�//1 /JG jf,/ above,also submit one copy of this form within 30 days of completion of well
f �/� 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) 6 Method of ... 81 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: Amount: ! completion of well construction to the county health department of the county
where constructed.
nar_1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016