GW1-2023-02101_Well Construction - GW1_20230307

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Fpntractor Informah'gq -
�y-r ci ei 14:'Vi'ATERZONES I I
FROM TO • DESCRBTION
Well Contractor/ Name ft. ft.
tr
`'f'4/ /4 R R . i
NC Well ntractor Certification INiumber 15.°TITER CAS11!IG.(£orinultf-cased ivel s)ORLINER'(if applicable)
S i i p,o,,,
•� FROM TO DIAMETER THICKNESS MATERIAL e_ -vi, , d.
Company Name // 7 1.6.INNER C. ICVG UR''TU$IIdG(Reothecoral'close -loon)
2.Well Construction Permit#: A // �O FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permit (i.e.Elk,County,State,Variance,etc.) ft ft. in.
ft
3.Well Use(check well use): • E ft. in.
SCREEN
Water Supply Well: FROM TO ,DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural .E3Municipal/Pilblic ft. ft. tn.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft, ft, Jr.
Industrial/Commercial OResidential Water Supply(shared) 1s..tROIIT
Irrigation FROM TO MATERIAL ,-{i' EMPLACET METHOD&AMOUNT
Non-Water Supply Well: 0 f- �D ft f Cy1�.y11 I f- kieME 15 ljr
Monitoring Recovery ft. ft �J
Injection Well: -
ft. ft.
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Aquifer Recharge Groundwater Remediation• 19,SAND/GRAVEL PAGK:(if;applicalile)
Aquifer Storage and Recovery is 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 'are" 0Stormwater Drainage ft ft
Experimental Technology \`•' OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.'DRILLING LOG(attach additional:sheets:ifnecesaary)
ex FROM TO DESCRIPTION(color,hardness,soil/rock type,(Hain sire,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) Q ft ft�1 I in (• l ay
4.Date Well ,—lf /l
s)Completed: � 3 Well ID# • �I 1 ft 05 k• /,'t(41-v11tE
ft ft
5a.Well lLLocatiion�•�/1 n
Facility/Owner Name Facility ID#(if applicable) ft. ft.
3LA2 a 11 ;s 51,. ft ft. MAR. t) 7 2U 3
Physical Address,C•ty,,and Zi ft. ft tt;,:_,e:•:;:,:;1 r'r,^_`. .••-1 !t„�.
Auther O)(A --21.REMARKS F.'' i:r ';,),.- ..
- County Parcel Identification No.(PIN) • ~�'r itz)&k -I --,23
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5b.Latitude and longitude in degrees/minutes/seconrjs or decimal degrees:
(if
wwelll�fiieeld,one laQt/lonng is sufficient) 1. 4)34 1� •
22.Certifleat(on:
4)-- .7,-p--on
_____6..Is(are)the.well(s) Permanent or Temporary •: Signature of Certified Well Contractor • Date
By signing this form,1 hereby cer11 that the well(s)was(were)constructed in accordance
7.Ls this a repair to an existing well: [)Yes or No with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,Jill 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 baglc of this form. 23.Site diagram or additional well.detalls:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop`Geothermal Wells having the same
construction,only 1 GW-1 is needed.•IndicateTOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: • SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 6,45" (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(exiiiptple-3( 200'aandd 2Qa 100') construction to the following:
10.Static water level below top of casing:% v v (i.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+"l 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6/4- (IQ 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
Dt�Y above,also submit one copy of this form within 30 days of completion of well
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
13a.Yield(gpm) i Method of test: e"-"I r 24c.For Water Sutrly&Infection Wells: In addition to sending the form to
r� I s the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 0.-11‘-1 0 Y.I VLl? Amount: 2 C S completion of well construction to the county health department of the county
where constructed.
•Form GW-i North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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