GW1--06554_Well Construction - GW1_20241101

WELL CONSTRUCTION RECORD (GW-1) - For Internal Use Only:
1.Well Contractor Information: 1
roVikn W
14,WATER ZONES- `r., ..
FROM TO ' DESCRIPTION
Well Contractor Name
sr fL iSc f4 3 tl
,49rn
24 I g ft. ft. 19C
NC Well Contractor Certification Number ,15::OUTERCASlNGOoi mutt-eased:"wellsj:ORLlNER_(ifap licable) • . •
C-' .e,.,, g (- _ s e+ ip li, FROM TO� DIAMETER I THICKNESS MATERIAL
IYJl�/�� 9 0 ft. ( I ft. (,tl(C. ..m ,[N
Company Name �j SI l l+
&INNERGASING ORTUBINGt(geotherinWCI sed4nOp)r
2.Well Construction Permit#:LI.,Ot'J L 2073— ��U SS FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State,Variance,etc.) ft. ft. m.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN ;::
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural i Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) csidential Water Supply(single) ft. ft. in.
Industrial/Commercial :Residential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. r�I s?P� ft. Oe it.,
Monitoring fRccovery ft. L ft.
Injection Well: ft. ft.
Aquifer Recharge 0 Groundwater Remediation
19.SAND/GRAVEL PAC&.(if applicable)
Aquifer Storage and Recovery DISalinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stonnwater Drainage ft. ft.
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) OITracer 20 DRILlING LOG(attach additional sheets if necessary) • :-
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
r��r rt. 7 ft. (1 I a n
ivirec
4.Date Well(s)Completed:-7I Si `7 Well ID# j )� it. `I.205 ft Vl �d�
`'{ ft. ft.
5a.�Well C ,Loocation:
lr i 1i..ln `��t'^
1 ft. ft. `1
Facility/Owner Name Facility ID#(if applicable) ft. ft. t,+ U,
w ft. ft. NO V 0 1 2014..�.
Ph,ical Address,��s,�Ciityy,,and Zip ! ft. ft. Ir`J:; ; :�
/l:t Y A l Olk4()S 5,3—�9�5 '21..REMARKS..:-. ,., f `2 z a'. •"::.
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
' S.F500 N 82. ZOO w 11 4 (A, fr 'l1xj2L1
6.Is(are)the well(s)ail'ermanent or (Temporary Signature of Certific Wcll Contractor Date
By signing this form,I hereby certify that the well(s)was(Were)constructed in accordance
7.Is this a repair to an existing well: DYes or m No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information explain the nature of the copy 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:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 'Z,C) (ft-) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: CPO (ft-) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: l._l/ lq (in.) 24b.For Injection Wells: In addition to sending the fonn to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
f 1�� 24c.For Water Supply&Injection'Wells: In addition to sending the form tong
13a.Yield(gpm) Lap Method of test: ��
�,� E_ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 11�-�5 completion of well constriction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016