GW1-2023-02811_Well Construction - GW1_20230417

WELL CONSTRUCTION RECORD (GA-1) For Internal Use Only:
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I.Well Contractor Information:
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V�fZM� V 1 fi"G 1 y — FROMA1ERZONES, DESC[tD'1TON
Well Contractor Name ft 1 ft
'3 z - fL ft
NC Well Contractor Certification Number F5.OUTERCToING for-multi-cased'meft ORLMER a cable
FROM TO DIAMETER; 'THICKNESS MATERIAL
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1�T�7 ?�,yn 0�/i r'��••� ��(i R f� ft. in. I Lf �b I/
Company Name 16.INNER INVG OR 1 fIBING Closed-loo
FROM TO DIAMETER I THICKNESS I MATERIAL
Z.Well Construction Permit#: ft ft. In.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)
ft. I ft in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM MTODMMNETER SLOT SIZE THICIINESS MATERIAL
Agricultural [3Municipal/Public ftL � `o n L(QGeothermal(Heating/Cooling Supply) Residential Water Supply(single) ftin.
lndustriai/Commercial Residential Water Supply(shared) 18.GROUlrri align FROM ATERIAL EM�LACEMENT METHOD&AMOUNT'ft ft I�a
on-Water Supply Well: 1
Monitoring Recovery ft ft
Injection Well: ft j fL
Aquifer Recharge DGroundwater Remodiation
19.SAND/GRAVEL PACK a Ilcatite
Aquifer Storage and Recovery [3 Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test O Stormwater Drainage ft• I l p ft 5 Q N✓ jJ o v/e✓ .
Experimental Technology Subsidence Control R fL
Geothermal(Closed Loop) Tracer 20.DRILLI G.LOG tattm&AMdihianel'slieetdfR.aeeesss
FROM TO DESCRIPTION cobs hnrdneas,salllrock blie,grain slay,eft)
Geothermal(Beating/Cooling Return) MOther(explain under#21 Remarks)
4,Date Well(s)Completed: r I t.f Well ID# (' ft �p ft Sir
t ft ft.
5a.Well Location:
ft. ft
j,Vk t i-r� ay(1 S
Facility livable ft ft.
pFa�cility/Owner Name ,[ f"5 n'ID# rf )( !f [, (�
is /�9n J S <<a HL 20 �D Z ft ft APR1707,
ft ft
Physical Address,City,and Zip
l�C` -T e,,6T ,, .v �•v
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wcU field,one lat/long is sufficient) 22.Ce tion:
i lure of I ertified Well Contractor Date
6.Is(are)the well(s)OPermanent or e orar mpy
_ signing thl(("ss form;1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or with ISA NC.HC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this 41 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 di am or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may a the back of this page to provide additional well site details or well
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells cortsutretioii details. You may also attach additional pages if necessary.
drilled: SUBMIT 11AL INSTRUCTIONS
9.Total well depth below land surface: (ft•) 24a. For 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: A) 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: (in.) 24b.For tl n Well In addition to sending the form to the address in 24a
12.Well construction method:
✓�C/ above,alo submit one copy of this form within 30 days of completion of well
constructio to the following:
(i.e.auger,rotary,cable,direct push,etc.) j
Divisio(t of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) Method of test: 24c.For Water Supiplv&Injection Wells: In addition to sending the form to
the addres(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount' completio of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality- ivision of Water Resources Revised 2-22-2016