GW1--05318_Well Construction - GW1_20240906

LI INIt I I.JIIII
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
•1 vis•V I r e,P.n _ 14.WATER ZONES
Well Contractor(( Name FRQ>•t ft. `(O ft. (arm TO
LIL. A ft. F W ft. ltA.�J
//N�tC Well Contractor Certification Number " ,(1 \� 15.OUTER CASING(for multi-casedtl wells)OR LINER(if a icable))
TO
WI r`-`t•�` ,`�i�L'��/t,� vat
P'1smL/ W 1 11 Il . FROM
tt, ft. DIAMETER/n(/t I. in. THICKNESS MATERIAL
Rt�-,,t
Company Name f jL-- �k' i�f
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#(0D ^ ^j FROM TO . DIAMETER THICKNESS , MATERIAL
List all applicable well construction permits(i.e.UIC,County.State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) viRcsidential Water Supply(single) ft. ft. in.
Industrial/Commercial (Residential Water Supply(shared) 18.GROUT
irrigation FROM TO M_ ��-h�j ATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. / IL.1 ,ft• Itiyr//r2rSl� li
Monitoring E3Recovery ft. ft.
injection Well: ft. ft.
Aquifer Recharge E3Groundwater Remediation 19.SAND/GRAVEL PACK(If applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL. EMPLAACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology QSubsidence Control tt. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Coolin^g7Retum) , `Other(explain under#21 Remarks) /'� ft. ft.
4.Date Well(s)Completed: 1 12))LL Well ID# GOft. i` ft. ?ad,
yft. 1Fvvft. ! l
5a.Well Location: .-
�Yr7�lrt S COY wiry) ft. ft. . % LP , 'J i.�Li
Facility/Owner Name Facility lD#(if applicable) ft ft. S E P 0 6 2024
7-1 V ietgi 3c i iMie` Vlia4j �J I J U j ) 2g 1 iti
ft. ft.
Physical Address, ny,and Zip ft. ft. info m-44fn i''�.r:rt+4,71 Ufa
21.REMARKS w`-
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.Certification:
c .412 N 12 W "7,---, I 71 DjZ4,
6.Is(are)the well(s) Permanent or Temporary Signature of Certified Well Contractor Ddte
By signing this form,1 hereby certift that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or 5No with 15.4 NCAC 02C.0100 or 15A 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: ? SUBMITTAL INSTRUCTIONS
1
9.Total well depth below land surface: i I() (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 2groo) construction to the following:
10.Static water level below top of casing: 3D (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: (it J.t-f It (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: 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) Method of test:Z'V ililtiYS 24c.For Water Suauiv&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: MeTt Amount: IS 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