GW1--03949_Well Construction - GW1_20230612

WELL CONSTRUCTION RECORD (GNV-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft, 8 (t. S
ft.
NC Well Contractor Certification Number 15.OUTER CASING(fur multi-cased wells)OR LINER it a licable)
TO D1AP1FTk:R TFIICKNFSS ;1fATERIAL
\V�►Iy_✓..�(,\ "ilY-!,1 W �./ ft. s, ft. 1 CP4,.,-
Company Name j �/��(pt�7 GrQ 16.INNER CASING OR TUBING t enthert ial closed,loo
2.Well Construction Permit#: / -' t�n V I 1 FROM TO DIAPf ETF.R TElICKNE.RS MATERIAL
List all appticable well construction permits(i.e.L11C.Counts State.irariauce,etc.)
ft. f[. In.
'? fL ft. in.
3.Well Use(check well use): �,ts
17.SCREEN' .
Water Supply Well: FRONf TO I DIAMETER SLOTS15. TIIICKNYSS MATERIAL
Agricultural [3Municipal/Public fl. ". &_- "I. i AM J !!tso
Geothermal(Hcating/Cooling Supply) esidential Water Supply(single) ft. fl. In.
IndustriaUCommercial [311esidenlial Water Supply(shared) 18 GROIST
itTi ation FROM TO MAI'EI1L►L EMPLACEMENT NiETnob&AMOUNT
,Yon-Water Supply Well: r tt. ft tJ
- ASoniionng - - - Recovery - - - -ft..- - - ft. - -- - - -- --- -Injection Well:
,Aquifer Recharge Groundwater Ren)ediatiwm 19.SAND/GRAVELPACK if a' licahle
:31Aquifer Storage and Recovery OSalinity Barrier FROPf TO I r.1.4TERIAL EPIPLACEMENTMETROD
Aquifer Test 1IStormwater Drainage n, ft. OF Cfl\
Experimental Technology Subsidence Control ft. tL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary
Other(explain under 021 Remarks) FROM To DESCRIPTION(color.bardaess,svivrock a c, rain sire,etc.)
Geothermal(Heating/Cooling Return) ( n, ft. a s
.r
4.Date Well(s)Completed: 5.3 well ID# ' rt. n•
ft. ft. _
5a.Well Location:
Q 1 1`
t�s>sh Ab�2 �y\ICi�P� ft. ft. ''v 4.�.>e e o
Facility/Owner Nam: Facility ID#(if applicable)
ft. ft. 1 I O L��
m l'LJ
ft. ft.
w ft. in , r�r;a:.t �:'.�.� � l;n%
Physical Address.City,and Zip
21'.REMARKS,
County Parcel identification No.(PIN) r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latlloug is sufficient) 22.Certi at(on: ��.
e3.5.6..0 JR-2 N 77-7./O'9 �. W r► .. 1^�
6.Is(are)the wells) ermanent or Temporary
Signature ofCenlOcd Well Contractor Date
By signing this forrn,I hereby certify'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Ycs or with I SA NCAC 02C.0100 or I5A NCAC 02C.0200;fell Construction Standards and that a
If this is a repair,fill out known well construction information and arplain the nature of the copy of this record has been prmided to the mll owner.
repair under#21 remarks section or on the back ofthisform. 23.Situ diagram or additional well details:
8.For Geoprobe/DPI'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: (ft-) 24a. For All Wells: Submit this fort within 30 days of completion of well
F: r nathiple wells list all depths ifd construction to.lhe,following:.fferent(example- Ca} )
10.Static water level below top of casing:, / ' (ft.) Division of Water Resources,Information Processing'Unit,
If%vier feel fs above casing.use"+� 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For infection Wells: in addition to sending the:form to the address in 24a
above, also submit one copy of this form vdibin 30 days of completion of well
12.Well construction method: �V� construction to the fi�Alovving:.
(i.e.auger,rotary,cable,direct pushy etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONI Yi 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) INethod of test:_ 24c.For Water Supply&Injection 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: C�/1lfii L Amount w®�. completion of well construction to the county health depann)ent of the county
where constructed.
Form GW-1 North Carolina Department of Environrrmenml Quality-Division of Water Resources Revised 2-22-2016