GW1--03993_Well Construction - GW1_20230612

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well7P,-(r&'tt
tractor Information:
pg—d, 44:tWAT,ER,ZONES.,4
Well Contractor Name FROM. TO DESCRD'TION
/,,� J� ft. ft. � ''
NC Well///Contractor Certi`fication Nu her CTAING'15:,OT1ERtOFROM DtlIA cMaEdeTdE:wReils lUR"LINERC a' lleable
THICKNESS MATERIAL
Company Name r
/ � �6.o.INNERt:C'TASIlVG'UR1T[1B�ETERhOrmalTHIC[QVESS "�k.MATERIAL'::
2.Well Construction Permit#: �'�/C 17 �0��1 /J(p J
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. In
Water Supply Well:
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERAAL
Agricultural QMunicipal/Public ft. ft. It
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
Iudustrial/Commercial QResidential Water Supply(shared) jggr,GROUT,,,
IIrI ation FROM TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft r .o ft' e° 1. e)t l b b 5" 0,5[t Y
Monitoring CIRecovery ft. ft.
Injection Well: ft ft
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13 Stormwater Drainage ft ft
Experimental Technology Subsidence Control % ft.
Geothermal(Closed Loop) OTracer Y:20::DRII LIIVGI O'G Otach,\saddltton>tl.eheeb'if ueeeaea ',
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks FROM To DESCRIPTION color,hardness,saltfrock t In a etc
D 1 ft 1 �11
4.Date Well(s)Completed: Well ID#
[t, ft.
5a.Well Location: —
t l J y e.
L (� [j���ijer ft. ft
Facility/Own lame Facility ID#(if applicable) ft. ft
3 ��� �,.l�'1a,i��n��• ft. ft.
Physical Address,City,and Zip ft ft T4j%:l Prcc7 aLm
County Parcel Identification No.(PIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
i.5• .�� S N W
�y
6.Is(are)the well(s)&r-rmaneut or Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certfy that the'well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or JoNo with 15A NCAC 02C.0100 or ISA 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 thisform. 23.Site diagram or additional well details:
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 I GW-I 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: 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 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 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: y C l' j 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 276994636
1
13a.Yield(gpm) 13 Method of test: 6+_1 j^ 24c.For Water Supply&Iniection Wells: In addition to sending the form to
l the address(es) above, also submit one copy of this form-within 30 days of
13b.Disinfection type: t'?.ti 1 U '_Amount: Lu 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