GW1--06225_Well Construction - GW1_20241021

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WELL,CONSTRUCTIONt RECORD (GW-1) Flay Internal (ise Only:
1
1.Well Contractor Information:
rr I�5 I
��vSl.'i U 1� �?)5' l.t.WATER ZONES I I
Well Contractor Name FROM1'O DESCRIPTION
`I` I‘6 I A �15 /csft.
Pit 4il-?z
It
Nt Well Contractor Certification Number -
IS.OUTER CASING(for multi casediwells)OR LINER(if applicable)
-S a I FROM I TO DIAMETER , THICKNESS I MATERIAL.
ft. ft. DIAMETER
Company Name I
to.INNER CASING OR TUBING(teothermal closed-loop) _J
2.Well Construction Permit#: I FROM I TO DIAMETER' THICKNESS \LITERIAI.
1 tst all applicable well constt7:cnon perm fis(i.e.1.7C.C'nrintt.Stu!e. l'ariaine.e2.r d ft. (]c it. t_� in. S ��JJ Ic\ 11 0
V VC-
/I,/j
3.Well Use(check well use): rt.
7 ft. in.
Water Supply Well: 17.SCREEN
FROM To DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal.!Public 67� ft. /05
t't. 4 in. q 69 o Scc).LI v Pvc
Geothermal(Heating/Cooling Supply) 2esidential Water Supply(single) rt. . in.
Industrial/Commercial DResidential Water Supply(shared) IS.GROUT S
,ilrtiP,ation FROM I TO I MATERL\'I• EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: (3 It. C) ft, Ifi.t,i-lact,,c Po II /0 <5'
Monitoring DRccovery - n. I ft. Si
I Injection Well: -
ft. n.
!Aquifer Recharge iGroundsvater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FRo\I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStorinwater Drainage ft. r C 1't. � ��et) /J�`�
Experimental Technology Subsidence Control n. ft. i `
Geothermal(Closed Loop) [37 racer 20.DRILLING LOG(attach additidnal sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under;/21 Remarks) FROM TO DESCRII'TION(color,hardness,soil/rock type.Brain size,etc.)
It. ft.
1,Date Well(s)Completed: t- 3 ,2Ll Well iD# rt. ft.
5a.Well Location: H. ft. i
t4V��r OLrot.vto ! a
ft. H. l_'.:. :. 4, •' _-> n, -.ems Li
1•acilics,Owner Name Facility ID==tit-applicable) IL ft. i
Fe)olr'\It L,A, 5.:',1N4wi-avC VA_ '7475- ft. I ft.
ti. 1 ft. : - :�,�r;,-rr^e.
Physical Address.City.and"LipIli!r.l',r�tt� .. t __ c,1a S
l�\A e, 21.REMARKS iq' `i te•t.G'�tJ•il
County t) Parcel Identification NO.(PINT
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(if well field,one rat/long is sufficient) 22.Certification:
3S. uri/5$ N 76 , S-500 \\'
6.ls(are)the well(s) : ermanent or O }'Temporar ;t�itanur 0eniI)ed w' 1 •(onuactor Date
lit ;yninc this Tarim herehr cerO/i•than the wellts)was(were)consnvcted in accordance
7.Is this a repair to an existing well: DYes or r •do - I,!!'+1 .4'-(.'..I( 02C'.0/00 or/.5A NCAC 02C.0200 Well Construction Standards and that a -
11this is a repair,Jill out known 11.e11 co17 n71c1ion*matron,,ma explain the nature n1 the apt if this se c ia•d has been prnrialed to the well owner.
repair under.21 remarks section or on the back of this fbrm.
23.Site diagram or additional well details:
S.For Gcoprobe/DPT 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 details. You may also attach additional
construction.only 1 GW-1 is needed. Indicate TOTAL Nt)MB} R ol'wells pages if necessary.
chilled: Sll11MITTAL INSTRUCTIONS
9.Total well depth below land surface: j S (ft.) 24a. For Ail Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifth//erent(example-.rr200'and''a 100') e nmlfucl ion to the following:
10.Static water level below top of casing: C (ft.) Di\isiun of i\Ater Resourlces,information Processing Unit,
ai.n-n'foal a shore casing.rise" - 1617
1617 Mail Service Center,Raleigh,NC 27699-1617
,' I i
11.Borehole diameter: �� (in.) 24b. For Infection Wells: In addition to sending the tilrm to the address in 24a
altos e, also submit one copy of this!tiirm within 30 days of completion of well
12.Well construction method: � o\cZfy/ n-. -si on to the following: I
(i.e auger.rotary.cable-direct push.etc.) I
' Division of Water Resources,Underground Injection Control Program,
m,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Celntir,Raleigh,NC 27699-163(,
13a.Yield(gpm) S� Method of test: l'v., 24e. For Water Supply & Iniectioil shells: In addition to sending the form to
_ �1 the address(es) above. also submit olie copy of this form within 30 clays of
13b.Disinfection type: I-i i N Amount: t7` \t' : . completion of well construction to he county health department of the count
\there constructed.
Fort GW-1 North Carolina Department of Fnvironntenud t lu:dm-Division of Water Resources Revised 2-22 2ni 6