GW1-2022-10615_Well Construction - GW1_20221122

Rnt Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: I
�r�G COOL FROM
WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. V ft. yay
—1 S 77 A �ft. �O�C�It.
NC Well Contractor Certification Number 15.OUTER CASING(for multi cased wells) P OR LIIVER(if a livable)
FROM TO DIAMETER THICKNESS MATE/RIAL
�A w i �°�C Z�IL O ft. ft. in. s p R oZ I V c-
Company Name 1
2.Well Construction Permit# FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) Q ft. R' 1° S ct% Ljo P Vc
3.Well Use(check well use): ft. ft. in•
Water Supply well: 17.SCREEN
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural MunicipaUPublic ft. ft. in.
:]Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. &3 ft. 316 l4vle fi p follmj 4 Jha+f— ;n PlAce—
:)Monitoring ORecovery ft. �3 ft. N 4S� 1*
Injection Well:
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
f Experimental Technology OSubsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
1___ FROM TO DESCRIITION color,hardness,soiltrock t rain size,etc.
Geothermal(Heating/Cooling Return) i Other(explain under#21 Remarks) � ft. ft. D V'C�"b C
4.Date Well(s)Completed:to I3 AP well `Ew A 7A- 'o. ft. 20 ft. C
Sa.Well Location: av ft. 00 ft. L
V e1°nvn ,I E s k►l-t
Facility/Owner Name f_ Facility ID#(ifapplicaable) ft. ft.
y S15, o xrc>rd 2J kc,96,r d NC. A?-T/-7 q ft. ft. , NOV 2
Physical Address,City,and Zip ft. ft ,.D
21:REMARKS - 1f1i+J"""'•` +, - :'%, '^
Aerson
County Parcel Identification No.(PIN)
i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lavlong is sufficient) 22.Certification-
346.3y(.a 17 N - 751.90 13(02' w G�� Gam— `-1 ig-77 1U-13- a
6.Is(are)the well(s)�rmanent or IOTemporary Signature of Cenified Well Contractor Date
By signing this form,1 hereby certify that the we/l(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 1OYes or Fv--Ko 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 and 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: Nisi (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 r@100') construction to the following:
10.Static water level below top of casing: oZ s (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: 4, �� (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: „o}IG.Cy construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,i Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 42 Method of test• 610.JA .20 Ahr1 24c•For Water Supply&Iniection wells: In addition to sending the form to
the address(es) above, also submit!one copy of this form within 30 days of
13b.Disinfection type: H T 14 Amount: 3A O Z completion of well construction 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