GW1--05308_Well Construction - GW1_20240906

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well ontractor Information: / ,
Rt r � ��/// 14.WATER ZONES. -.. .DESCRIPTION
Well Con act N e
I-,y� ((0' 2— /1 ft. ft' )9fr1I A).;,1 .0-, IUW)1,747
/`d` l7 fr. ft. CZ,et) 49p
NC W I Contractor Certification Number ��/t/ 15:OIJTER.CASIP(G"(foe multi'cased".welti)"OREINER'(if'ip triable).
C.> l/ ,8r�5 : 1//�" ` FROM TO�t DIAMETER THICi MESS MATERIAL
fL Za`' ft. ��14 in, $I'/ I P I
Company Name
�v© /��� /j 16.INNERCASING;URTUBING.(aeottiermal'claedaooy)-
2.Well Construction Permit#: 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): rt. ft. in.
Water Supply Well: 17.SCREEN.
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural 0Municipal/Public O ft- ft. in.
MIGeothermal(Heating/Cooling Supply) [Residential Water Supply(single) ft. ft. in.
[ Industrial/Commercial Residential Water Supply(shared)
"Thifrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. ft. /3fr'0)
) v('AL'Jl )tA
QMonitoring II Recovery ft. ft. ! '� v�
Injection Well: fL ft. //
QAquifer Recharge *Groundwater Remediation
19..SAND/GRAVEL'PACk'(If applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test El Stormwater Drainage fL ft.
DExperimental Technology [Subsidence Control ft.DGeothermal(Closed Loop) OTracer 20.DRILLING::LOG:(itticti.additional slieeh1fubiesaii ):
fl Geothermal(Heating/Cooling Return) ',Other(explain under#21 Remarks) FROM TO DESCRIPTION(solar,hardness,00iUrock type Brain size,Na)
f� i a fL �'�" R. lJi'"LI'�p id�.�� G,tf11-�l
4.Date Well(s)Completed: _ , �"/Well ID# ` g 5 ft /V 12 fL ft jj 4:-AT
-�� •
5a.Well Location: /� /�t� t JJ 1 n,, P� ft. St'v fL Var1/ i ) /! `t 5'.5
L'p/Jinii",lvgPiggi 7pt //'la/ 9,V' ft. ft. V J
Facility/Owner Name Facility ID#(if applicable) ft. ft.
k
2/// h1P* Iiiiii r,' 5rl/l2 / d ft. fL `, 6 /�
Physical 71rreess,City,and Zip [..-h tl y l vTr a fL fL ' f 7 V 2024
24
r`jf7,,, .q r rT/ 21.REMARKS
/.`�j/✓�—/�(\ ififfi;'.aaCit l'",, ,r„C<-:,UrtX
County Parcel Identification No.(PIN) i)'fiC.:410G;
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) /] 22.Certification: /� �Q j� '
35- jticL9 L N V(1, l P i- 3V Y W 4a4r g-y- '7
6.Is(are)the well(s) ermanent or Temporary Signature of ified Well Contractor Date
By signing this form,i hereby cert fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: X Yes or Yo 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: _3!U.0 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiferent(example-3Qa 2000'and 2@100) construction to the following:
10.Static water level below top of casing: 2 9 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use +'j ji 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: Tr lin.) 24b.For Infection 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
11.Well construction method: /I '.' " 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) 7-3- Method of test))J/ " /'f,T 24c. For Water Suioly&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: /1/ /7 Amount t' a 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