GW1--06250_Well Construction - GW1_20241021

WELL CONSTRUCTION RECORD (GW-1) For Internal l ..CsOnl.: '` '° "'�""
1.Well Contractor Information:
--s1 �S
I14.WATER ZONES
FROM. IO i DE�CRI? ONWell Contractor Name
(,� j� ft. ft.
t1 I f [ 1'l. ft. ' . _.
NC Will Contractor Certification Number
- IS.OUTER CASING(for multi-cased wells)OR LLNTROfa,^ 6
'�S' FROMTO DIAMETER THICKNESS' i''4iti3A.E
l ft. ft. in. I
Company Name , t
16.INNER CASING OR TUBING(geothermal closed-WOO' = - ,
2.Well Construction Permit 4: -- - FROM TO DIAMETER THICKNESS 1 M.IM%tt
fist all applicable well con per,»its(i.e.-WC.Cot»nr.Slate, Variance.etc; 0 ft. ;.00 l ft. L1 in. L) 4 D . 1 161� ,
\J V
3.Well Use(check well use): lt. ft. in.
Water SupplyWell: 17.SCREEN I
FROM TO DIAMETER SLOT SIZE THICKNESS I _MATT.ERlAI.
Agricultural OMunicipal/Public 0,07 ft. „ Q ft. 4 in• 03D Stm, 40 LeG
111Geoihermal(Heating/Cooling Supply) OResidential Water Stipp') (single) ft. It. in.
i Industrial/Commercial DResidential Water Supply(,hared) ' '
r 13.GROUT
}litigation FROM '1'O -MATERIAL EMPLACEMENT METHODS.AM U(N T
Non-Water Supply Well: O it. n� ft. ,/f1 `tTw T4 tC{'
vt (POit�c
injection Well: y
h n. ft.'Aquifer Recharge Grounc <alcr Ltncdiatiru ;
:
19.SAND/GRAVEL PACK(if applicable) I
,Aquila'Storage and Recovery Salinity Barrier ,• -.ROM To MATERIAL- EMPLACEMENT METHOD
Aquifer Pest QiStorm\sater Drainage I%S tt• CJt: b ft. #� 15.< nbr
Experimental Technology D. Sub,idence Control ft. I ft. tt 1 J0.1 i... J' `
'Geothermal(Closed Loop) {^ ,Tracer1
tom! 20.DRILLING LOG(attach addifioual sheetsif necessary)
Geothermal(I Ieatntg/Coolntg Return) Other(explain under h 1 Remark ) I FROM .1 To 1 DESCRIPTION(color.hardness,soil•roct tsDA gram>ue.etc.,
4.Date Well(s)Completed: 7�a S-2- Well ID# p 1 /
liryl. ft. I aoO lt• L fiVe__54ot/IL
5a.Well Location: ft.
1� S . • ralI -i c. �.
al'ia .. _ .. f:. R. _ r _ ' e4'c. 1
FacihnaOwne Name 1-acility_ID,((I applicable) ft•
(� OCT 2, 1 2024
7 ..M,, IA 306 /f-v,rt,(r, LA/L 27o6 fl. ft. j . .
Physical Address.City.and Zip ft. ft. ILf:�;rr rc(cy,7,7Cr:r s k4i • ,
(3e.4v--cC•k- 21.REMARKS i:'r't t.4'3l,•
?:
i'minty Parcel Identification No (ITN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if+cell field.one Int:lon_i,sufficient)
22.Certification:
7St fit13 N "7b igS53
• ,r 2- D--thy
6.lc(are)the wells) ermanent or Temporary
denature d Certit d Well Contractor Date
_ �C/ !f) ae»,» an.1 n». I herebr.cern('that the u-ell(s)was(were;constructed in amcnrda.?ce-
7.is this a repair to an existing well: Dyes or F�t�-�I. ) a,r/,/,.1 \(-.4c•o2c al00 or I5`1.VC.4C 02C.0200 Well Construction Stcntdine.,and that a
flirt;iv a cc/nut;fill out 4•nowrt well construction hl/drmato;and e.rp/min the nature at the Copt 7;/this red cr l had been prortded to the well owner.
repair upim/er=21 remarks section or on the back oft/ifs jar»,
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.-For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction.only I GW-1 is needed. Indicate TOTAI,NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
• SUBMIT•fAl,INSTRUCTIONS
9.Total well depth below land surface: 2.Q b (ft-) 24a For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths,/ch/f"creoe(example-3'h._00'and 2 a 100')
construction to the following:
10.Static water.level below top of casing: P0-7 (ft.; Division of Water Resources,Information Processing Unit,
!I't+zaer level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: / 3/ti (in.) 23b. For Injection Wells: In addition to sending the form to the address in 24a
12. Yell construction method: 6 . above• also submit one copy of this forth within 30 (lays of completion of well
construction to the'Mowing: +
(t e auger,rotary,cable,direct push,etc.)
Dit ision of Water Resources;underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
•
13a.Yield(gpm) Q.S Method of test: Mp 24e. For Water Supply & Injectio�i Wells: In addition to sending the form to
t f the address(es) above. also subthit one copy of this form within 30 days of
13b.Disinfection type: t l H Amount: 9 i4 completion of well construction o the county health department of the county
w here constructed.
I oral(Dv-i North Carolina Department of Environmental Quality-Di‘i.tnn of Water Resource.. Revised 2-22-2016