GW1--05690_Well Construction - GW1_20240920

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WELL CONSTRUCTION RECORD(GW-1.):- '' , For Internal Use Ord • '' '' ' '-", '' - '' '. ,
1.Weil Contra or Information: , •' " • .- .
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14.WATER ZONES • , - • ,".t)OLVI. D001(4- • - '
• FROM TO DES RIPTIO .
Well Contractor Name ,.?,- '
/--''' 41i'al is< ' , oft 0 ft. - ...,.-„ ,. '
, // . ,/f- . , ,
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, - ''ft' c ft=' ..194.-- ' • - ':-''' '
NC Well Contract° Certification Number ,
Da‘it 1FR5.074UTER CASING(farm wells)OR LINER(if aprble)
. , ,, ETER. THICKNESS MATERIAL
, . ' ' .' ". ': ` ' ,• 0 4' /27 ft. . 62' ,"h. it4P':: ;pa... ,,
, ComPany Name ,
4.6.INNER CASING OR TUBING(geothermal dosed-loop) '
,; . ,,„ , ' , -• •FROM . TO• DIAMETER THICKNESS MATERIAL
-..- 1 Well Construction Permit 0: •
UIC C List all applicable well construCtionPermits(i.e. ,County State,V, Variance etc) - ft• ' ' ft
e . • . . ,
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3.Well Use(check well use): . '
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Water Supply Well: _ - .
17.SCREEN
FROM TO -DIAMETER SLOT SIZE THICKNESS MATERIAL
, - zi Agricultural • , , - - E)M 'cipal/Public-•
/14 ft- /IV ft #1,2 in. - c) ".54 4 -c.) ",....
C3 Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. - ft. ,in. ,
'Olndustrial/Commercial . ' EiResidential Water Supply(shared)
113.GROUT
' Irrigation ''• - • , , • . • FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply We.,:- , , , , 12, ft. 2 ci,,-ft.i,d91.46.-51es
C "'eP' '
Monitoring , DRecovery '• Z ' , ft. ft
Injection Well: . ,
. ' • • ft. ' ft
Aquifer Recharge , . - - IN .. dwater Remediation - '. ,
. 19.SAND/GRAVEL PACK(If applicable) .
Aquifer Storage and Recovery „ ' ISalinity Barrier - . , FROM TO - MATERIBL ' .EMPLACEMENT METHOD
-, Aquifer Test ' , 31 Stoimwater Drainage, - 472 fi., . ",...,,-
Experimental Technolo lt, - II ubsidence Control ft. • ft. . , . ,
Geothermal(Clos-• oop) , OTracer , - 20.DRILLING LOG(attach additional sheets if necessary) '- ', •, -
, -• - To . DESCIUPTION(co r.hardness,soWrock type.min size;etc.1
' Geothermal(•eating/Cooling Return) n Other(explain under Remarks) FROM - . . - - '
e:2 ft. .2 ft. ,z.,0, 0, , ,.. . , ,
. .
q tia. (a . - - -
. _, 4.Date Well(s)Completed ` Wall ID# '• '3 ,ft" 47"c,"' ft• , f 4, " • , ' -. '' • .-
,1 ' -5a.Well Location: : ?- 1 . '' ' '' , I ,,,%'. , • • 4Al/.It'•''' yr 4' jr010.:, ' . '72;:;-_,: ' T•„ , .'
tn6i t ,, c6v)tA - , ,. . . . yk
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Facility/Ow1ner N0a me A0- ' - 4, \,61 .Fay ID#'(i ppllcable) //0 ,ftft.UV 4
. . 1....i..)
0,a7,24
ft. Jr ,- ..,
Physical Addreas,City and p • - i ' etlii: 1 PI ft. - - ••-•-".r..c••••-, -3
Oiykivv,-‘/I, _
21.REMARKS •.- - , - , iLY/V47,.„-?0,--:::. ":.4 Lii•-•..?,-,
County • , .. Parcel Identification No.(PIN) ' , . '// e • /14,4, • ' '
' . 5b.Latitude and longitude in degrees/Minutestseconds or decimal degrees: ,' ., ' ',„• , ' , , • .
(if well field,one Lit/long is sufficient) • . ' ' ; 22.Ce.rtification• •
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N W• ,...,, ' . .
6.Is(are)the well(s)arrerma tient or E)Temp' orary, .,-, ' Signs f ertified Well Contractor ' , •- : - Date ' ,
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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: OYes or ta<1:: -' with 15A NCAC 02p.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 ortiOsed-Loop Geothermal Wells having the same •- ''•''l'.' ' .,./9.
, 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 - - = . • ,
' . • SUBMI'ITAL INSTRUCTIONS:,
9.Total well depth below land surface , •A7- ' (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 2@.100')'-." , ' construction•tothe following
• ' , ' ' :, .-..-',. , , ,, . •
.... f 10.Static water level below top of casing , - 00 ' ' Division of Water Resources,Information Processing Unit,' ',•' •
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If water level is above casing,use"I-" • - ' 1617 Mail Service Center,Raleigh,NC:2709-1617 ',• - if,
11.Borehole diameter- ,Cc ,(in.) . . ' 24b.For Iniection Wells: In addition to sending the form to the address in 24a
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. „ ' above, also submit one copy„of this form within 30 clays of completion of well
12.Well construction method:-
011%, . construction to the following: •
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0.e.auger,rotary,cable,direct push,etc.)•• , ,
, t • - -.
...------, . . ' 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: "ed-?! ---:-. ... 24c.For Water-Supoly&-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: 40.4% .• Amount: i d 7- - completion of Well constructidp',to the county health dePartnierd of the county
,.-- ted
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Form GNAI-1 ' ' North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016