_Well Construction - GW1_20230320 (32)

VV EiLilu V,..L1II01tCU4.-.11V1'o1 Kr..A.AIMILLI For Internal Use ONLY:
This form can be used for single or multiple wells
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1.'n/Well Contractor Information:io /r� �C' /
, 1 e/L,I-) 19e//1 ! V('F cey fLc CLdi e/' FRO ATER ZOONES DESCRIPTION
Well Contractor Name ft. ft. /(0/ 3 60 j,/3 o
036 .;; ft. it
i
NC Well Contractor Certification Number - 15:OUTER CASING(foi multi-ciised wells)OR LINER(if an'Edible)`:- "'• •:`•.
FROM TO DIAMETER/ THICKNESS MATERIAL
I� 4. m�rl1,s f J « Vrr'crc;nl, A/c. y, / ft /a oft, h'//s, in. 0 a s PvC
Company Name 16.INNER'CASING ORTUBING(geothermal closed=loop)" `: - .
FRO2.Well Construction Permit#: ` )(p(03'7 ci • ft. TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.County.State,Variance,etc.) ft ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft• in.
❑Geothermal(Heating/Cooling Supply) @isidential Water Supply(single) it in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENTg METHOD&AMOUNT
❑irrigation 0 ft ay ft VenFa,,,Y peicr d
Non-Water Supply Well: /
it. ft.
❑Monitoring ❑Recovery
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19:SANDiGRAVEL PACK(if applicable) ' . -
• FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft.
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING•LOG(attneti edditionof sheets if-necessaty) "'
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soh/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#2l Remarks) 0 R• . O R• Rod Grit. S
4.Date Well(s)Completed: J� ^- a• O it 70 ft �a,,,,,,� /L C e _$G
✓ c1D ft /aoft Beet SLa.+e
W ll Lacahon:5. /.?Q ft [�(�t�t VZ4 e J e.,=
1 IJ M,c ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft ft. ,— `T P''"7-'
R ', '. ti 4.-rs, a >` a— z,
/1/c7 McGee Rd. d .l aI4 .. ft. A ❑ A n
Physical Address,City,and Zip v MAR 9 2023
�� Zip 21.REMARKS I _
l M.C'il Irf7, : ^n ?t^:•-;:,, ::ri l.na
County Parcel Identification No.(PIN) DW ;;S:..bZ?
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
] il. 55967 N 7'3 F 15DS W / -.3 -Z3
Signature of Certified Well Contractor Date
6.Is(are)the well(s): permanent or ❑Temporary By signing this form.i hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ii1N6' copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction infOrmation and explain the nature of the
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 site details or well
' 8.Number of wells constructed: ( construction details. You may also attach additional pages if necessary.
For multiple infection or non-water supply wells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions:
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9.Total well depth below land surface: t 60 (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: (ft.) Division of Water Quality,Information Processing Unit, .
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If water level is above casing,use"+"/, 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: la<5� (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: r Ala r y construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) O Method of test: /9!r 24c.For Water Supply&Geothermal 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: Tl Amount: 3�r`/1 7F'S completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013