GW1--06416_Well Construction - GW1_20241025

i
p" E''ONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information•
ryy-ti Ad`] J� a14tWATER>ZONES a:t t ? d. ti,T ,+' ...�.�. w.,.ac,kn,.,». _r..,z.i
Well Contractor Name V FROM TO DESCRIPTION
ft. ft.
45Art. ft. I i
NC Well Contractor Certification
lNumber /� 'n t ///'/l -- it OUTEWCASING(for tnuli cased wells)>OR LINER'(lf ap'lleable) ,
`' �? l k' / l '/'i2 •• (,1✓,, u G FROM TO DIAMETER/ L `TH/I�CK/N�ESS MAyTE`R/IAL
(_1z >! /`�J1 , • i ft, a q ft. 6(`7 - m• .J n iz a) P )/ e,
Company Nagler� l6 DINNER;CASINGT.ONTUBINGIgeothermal ulo"sed=loop) • -1.:,f
V�"2.Well Construction Permit#: J/2l 1 I.)� q o FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft, ft in.
3.Well Use(check well use): ft. ft in.
allI?SCREEN .h st,4i.V. s1 K,II :.1 ,z . Pr' i , .v�r e_<_
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. • in.
0 Geothermal(Heating/Cooling Supply) P'Residential Water Supply(single) it. ft. . in,
❑Industrial/Commercial ❑Residential Water Supply(shared) 8r18t:GROUTa°tsI S ,a>:,.t f��.EI..;i ri a :__: :' 1',w--:-.ir
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: G fr. �Fl,l1e111 fG....}}•-- t p^!� d
ft. l"� ) a�
❑Monitoring ❑Recovery ft. ' ft.
Injection Well: —
ft: ft.
❑Aquifer Recharge ❑Groundwater Remediation s ,
.191 SAND/GR•AVEL"PACK(tfaapplicable), c.i•.x t. . .• -<,v ,,._,.> . Y;s•
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control • ft. ft.
❑Geothermal(Closed Loop) OTracer r 20i'DRIi;LING,LOG(tittactifaddihoaal(sheettrrf`ne'cessary)Y t.NA; , j.;. `. j,
FROM TO DESCRIPTION(color,hardn ,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
j '1 D ft, j t `l.ft, '.l l� , t.I L./,i/'�t ✓._..1
4.Date Well(s)Completed: 10 el"`2'Y Well ID# /3 0 ft, 3-6 5Z't. ( v`).t/ *e
5a.Well Location: ( ft. ft
G(:9^V IA)a-1 1 a C a. ft. ft. ::. ::. - I '.
Facility/Owne ame Facility ID#(if applicable) ft. ft.
46,23 U 6. O # ft. ft. OCT 2 L- '1 UZ4
Physic ddress,City,and •p ( ft. ft. li <V - , r 1r
Xf//—t t'C/ t61'd ,,,- ;REMARK3k+i1W,kt;.;f '':„y? ;,''.z, l?:�';.:1._>, . �rsh,.
County Parcel Identification No.(PIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(dwell field,one lat/long is sufficient) 22.Certification: I
a ��/ 4' I N — Ifg75"94 W J ' I
� �`,. �- le) q/, -al/
Signature efCertified Well Contract r Date
6.Is(are)the well(s): gilPermanent or ❑Temporary
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or EINti . ISA NC.4C 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy.
If this is a repair,fill out known well construction information and explain the nature of the 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:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells,having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 606 (ft.) Submit this GW-1 within 30 idays of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100') 1 .
• /� 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: r (ft.) Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: vi A. (in.) Program,1636 MSC,Raleigh,INC 27699-1636
12.Well construction method: Ji"O 1 (/I 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
I Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: Q...1
J t
13b.Disinfection type: eh 1 Dr/yi Amount: r'.)
., L' ly 5
l '
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018