GW1--06408_Well Construction - GW1_20241025

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1
,.. 1.Well Contractor lnformadon:
r.tiPhi%lle g ilPii ii ky
14.WATER ZONES
I I
FROM TO DESCRIPTION
Well ContfactorNarne
i itCk M-D
• 3S--iVl ,
‘ '2 -1t AL.S"-ft- t 18 PI in
NC Well Coteractor Certification Number
IS.OUTER CASING(for tnnItIcased wells)OR LINER(if le)
FROM ro DIAMETER THICKNESS MATERIAL
He/is fe il 1-& lag II br-‘, Iii u in. C. • IL 7.CIL 6,Ytt in'
Company Name
16.INNER CASING OR TUBING-(genthermel closed-loop)
2.Well Construction Permit ll: to P-A 3- - FROM TO DIAMETER THICKNESS MATERIAL
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Lis't all applicable well construction permits(Le WC County.Slate.Variance.etc.) rt. ft. in.
17.SCREEN i°-1
3.Well Use(check well use):
IL ft.
Water Supply Well:
FROM TO DIAMETER ' SLOTSIZE THICKNESS MATERIAL
13Agricaural OtfimicipallPublic ft. ft, , in.
1,
ElGeothemial(Heating/Cooling Supply) %Residential Water Supply(single) ft. ft. in.
°Industrie' 1/Ccmmtercial ['Residential Water Supply(shared) 18.GROUT
°Irrigation OWells>100,000(3PD FROM TO MATERIAL ,RW*CEMENTESTigtOD&AMOUNT
Non-Water Supply Well: 0 IL 71 0 IL 71271,4Mt- Pa 41./aeA
['Monitoring [Recovery
Injection Well: , .
ft. ft.
ElAquifet Recharge .., EIGgrundwater Remediation : - - .
19.SAND/GRAVEL PA. (ir applicable)Al bi-
['Aquifer Storage and Recovery OSalinitY Barrier FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Test OStormwater Drainage IL II.
°Experimental Technology OSebsidence Control . . 11- • ft.
°Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(anon hardness.scant&type,grain size,etc.)
°Geothermal(Heating/Cooling Return).. °Other(explain under#21 Remarks) lir
. n ft- ft
4.Date Well(s)Completed:/03/-20 4 Wei IDll (de-.23---.-0Z- A_
ft. 6 0 ft. 110 Pc ii,:4.). i
i Sit.well Location: • .... „:: i S '•:6-;:;It*:. ,L-,.72:5T---.7, r ::• ',e4e . ni:1 - eL.:.,,,, '-...-,...,:-.-.v
,, . 1..-ff..t, : -:...,
1 .„, k,..i-,t t•-',11 ' - -.1.,.•. (.1.:i71,"1'.'.7,
1----K-oCt :-D='eon ki--6--r-2--- --- ---- ---------------. --,-----------7„,-,----' -1 S- --q'X' 64/..Qi.27A2 t.g-,:rz9ck_
Facisty/ownermane,,,,,,...: .,,,-..,i:-:, A : faofityjp#11fapplieebtel.....___., c,',....,..i,- .-. 1::::::.F.,F.„;;::-ki.kij,;-i.j7,1:: :•,:!,-,,-..:5.,_,,,,,„,..,,,;,,:,,-;,,I,,,,,;',.i .F•i:co .,.-(;
I t,..d":, t5---R in et'64/rkierg-Vg-14.0thri A)C., " -,-,.'..-,,ft.r i, :. -!;5,'-'Vf711.:C':' t,-f''''P.---t*, '..71•:! ,
•
i --- --. 1.. i -- i-'
Airi g'6"-0 -- -.7_:.i.- T:-::,-11.,-.: .::: :;',:.771!W ,..,.)!::- :;',..vi.:_-.-'--&•:ti.--.e,,17.-',::,i':-.07.-".;,,a'::1;:i'''.:V.• "-, '-
PhVaical Addrektiti,iand Zip t'.- •
-• 4,4 1r reAej, :,..'-. ,'1 c -
_ __ 21.REMARICS -. .. : . ,.,' 1.-•,..••-•?:"i.•.-•°-:.' '!.':'- ':....,1
.. ..... . ..._...„. . . , . . . ..
., . • ..
5b.Latitude and longitude in degrees/ininuterfsecands or dedmal degrees: ' ' - • •'-' ' .. '-.-' ' ''''' " v 'OCT 9 .; '9024
,/ • . ,
(ifwell field,ane latfiong is=Mihail) 22. ,1 i 7 on:/p . 0-il--7."••• •1..-:-,.:._,.,.., .,...,
3 3=2. ?j.,4) . N Irl. 5'7 gc-Pf w •,f/ -•. . i 0iuk..„,(../,:.3
:•I- .. ,
, • - i ,2 )-0.2-
,,.,: •
. 6.Is(are)the well(s):
['Permanent or ['Tem s tore of ed Well Contractor porary'
. Da
Ily signing this form,!hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an mishit g well: bYes or VIVO • 154 NC4C 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a cop;
ythis is a repair-.fill out known well construction information and explain the mane ofthe ofihis record has been provided its,the Well owner.
repair under#21 rernarlssectionor 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 construction info
construct*,tadytQW,1 is_needed..Indicate TOTAL NUMBER of wells (add'See OVers in Remarks Box):You may also attach additional pages if necessary:,
1 , .
driuixt: • / " _....
24.SUBMITTAL INSTRUCTIONS .9.Total well depth below land surface: 02 - il
.(ft') Submit this GW-1 within 30 days of well completion Par n per the following:
itdtipleue 1 l i list andeptlii f different(exaniple 3@200'and 2g100')
Maticwater.level belowtop of casing' : ‘..' ,s 24a. For AU Wells: Original Tam to Division.of Water Resources (DW R),
t"- Informatiortyrocessing Unit, 6I7-MSC,Raleigh,NC 27699-161T
frivoler level is aboVe caving.use"+"
, !
III Borehole diameter:,:•:, 6 -..- .. •, ,..,- , 24b.For Injection Wells:Copy toiDWR,Undemtnnal Tojediort Control(RIC)
- ----
Program;1 p6 msc;ita!ei-gh; 27699-1636 i;--: •.::----''.'.:• ';. .'' '--' '1' .'
12.WellitiiistSuctidintillind: - fil seo,779-12. • 24c.For Water Supply.andOpreo-Loop Geothermal Return Wells:Copy to the
0,e-,VIllcr,JotalY:9131e,&Feet Push.etc.) ..4 !-...' ----• •-• county environmental health department of the county where installed,--------''
FOR WATER 64UPPLY WELLS ONLY: A 24d.-Far Water Wellitirdiliiiiiiiiiiiif:100,4100 GPI) Copy to i1WR,CEP-CU---AT;
--il`,•-,:`-'.:.,-..‘v 13a.Yield(gpm) I/0 - Permit Programc161 1 MSC Raleigh,NC 27699,1611_..: •, - ..,----.. ---•
'•' • .._ ....-,
ieh; /:2 -41-
13b.Disinfedion typjyg e- r -e--Amount 21)7----
. , . . . . ., .: . - • . _. . •. .
Form 61.4-1 ' Nord'Carolina Department of Environmental Quality-Division of Walfr Resources ... Revised 6-6-2018
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