GW1--06190_Well Construction - GW1_20241021

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor Information:
7vt l e5fi?S5- 14.WATER ZONES 1 I
Well Contractor Name //// FROM TO DESCRIPTION
Well
(+ 0. ft. I I
'I M ,(J//-� rt. ft. 1 I --
^:( Well Contractor Certification Number IS.OUTER CASING(for multi-caied'wells)OR LINER(if applicable)
�V� HAD�t�t �/'r((it FROM TO DL4METER THICKNESS I MATERLAL
ft. ft. in.
Company Name 1
16.INNER CASING OR TUBING(geothermal-closed-loop)
2.Well Construction Permit 4: FROM TO DIAMETER THICKNESS MATERIAL
List oil applicable well construction permits(i.e. UIC.County,State. Variance,etc.r 0 rt. r'1 1 l D ft. Li in. C`)'`IO 1rV' L- 1
3.Well Use(check well use): ft. 7 ft in. 7
Water Supply Well: 17.SCREEN V
FROM TO DIAMETER, SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/public Aloft. 93Oft. i' ,O D Sec �L-
L{v I�
Geothertnal(Heating/CoolingSupply) DResidential Water Supply((single) 7t ft. ft. in.
[�ILrlu54'ial%Conunercial D Residential Water Supply(shared) ' 1S.GROUT i' f
rr gation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT i
\\'aterSuppl} Well:
ft. 9� ft. A k7�f�i'` �`�r
Non-Water
-- Recovery rt. ft. z !
Injection Well:
, lquiter Recharge DGroundwater Reutediation rt. I ft.
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATEHIAI. EMPLACEMENT METHOD
'Aquifer Test DStoronvater Drainane rt, ft. 1
'Experimental Technology DSubsidence Control 3 ft. rJ�D ft. #� j ScwS
c�c,tr.
'Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness.soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain undern'_l Remarks) ft. ft.
-� j
4.Date Well(s)Completed: /-�5 O 1 Well ID# ft. ft. ii.
5a.Well Location: jCj.7 ft. ,23c iL LLSAAe.-
ft. ft. i
Facility Owner Name Facility ID=(if applicable) ft. ft. "i.;a.(,`,"C., V::L)
917 O 6N C.. 3O6 //fit t '' c- 2:70 G ft. ft.
Physical Address.Cits.and'Lip I ft - ft.
OCT 1 2024
21.REMARKS .. 1r.,f, r7tr 'sue P-r.. .:,n,2 n.r:t!,.Nt
Q'rCQ
County Parcel Identification No (PIN)
5h.Latitude and longitude in degrees/minutes/seconds or decimal degrees: !,
i ii ts ell field.one lat'long is sufficient) 22.Certification:
IS.a 674 N 7f�: 6. 6`i \\� p., 7a6�a�
6.Is(arc)the w'ell(s) ' Permanent or DTemporarySion:Lure of enilied Weontractor Date
/ii sitnug this/br,,,.1 hereby certljr that the wells,was(were.)constructed in accordance - -
7.is this a repair to an existing well: Dyes or o nati!/3A RC.4C'02C 0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
it thus aa repaa,fill out known weconstruction rnforrmwian and explain the nature ofthe cope of this record has been provided to the well owner.
r oarr•under-=21 remarks section or on the back of this Arm.
23.Site diagram or additional well details:
S.For Geoprobe/DI'T or Closed-Loop Geothermal Wells having the same You may use the hack of this page to provide additional well site details or well
construction,onlyI GW-1 is needed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages it necessary.
drilled: SI:MITI-rm.INSTRUCTIONS
2
9.Total well depth below land surface: Q J 0 ft. ,'
( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths lidy.lbrenr(example-3 i 200'and 2'u./00') construction to the following: li
1
10.Static water level below top of casing: i Q? (ft.) Division of Water Resources,Information Processing Unit,
if water level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: 371 (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
R above. also submit one copy of this form within 30 days of completion of well
�9�t+12.Well construction method: L-\/ construction to the following: I'
(h e auger.rotary,cable,direct push,etc.) + +�
Division of Water Resources,Underground Injection Control Program,
FOR 1VATER SUPPLY WELLS ONLY: 1636 Mail Service'Center,Raleigh,NC 27699-1636
13a.Yield(gpm) S Method of test: jPi,t.I4 24c. For Water Supply & inie Ition Wells: In addition to sending the form to
�" I the address(es) above. also sub! i one copy of this form within 30 days of
13h.Disinfection type: �Tr1 Amount: )1 ' completion of well construction to the county health department of the county
where constructed. 1
arm GW-i North Carolina Department of Environmental Quality-Division of Water Resourc s. Revised 2-22-2016
I