GW1--04305_Well Construction - GW1_20230626

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 1...........7-
1.Well Contractor Information: �ry�
/�'ir t s'Y 6+J i' it \ '14.WATER ZONES
Well Contractor Name VVV"` FROM TO DESCRIPTION
ziOq - 1 )(o ft- 3?o ft- WI
d
NC Well Contractor Certification Number -15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
yl I^ �7 e,y`n r„ ( I I�� ' FROM TO DIAMETER THICKNESS I MATERIAL
'J`�, [7 J �G V`(rC.41 ft. ft. in.
Company Name
'16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: a 0:a"' V b 353 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) V ft. 56 ft- A ZS in' SD 2 I PVC,
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM
SCREEN ,
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL _
®'Agricultural IoMunicipal/Public ft. ft. in.
®Geothermal(Heating/Cooling Supply) DRes. ntial Water Supply(single) fE ft. in,;
MI Industrial/Commercial esrdential Water Supply(shared) 18.GROUT
-i Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. /l0 ft• he h le Hxo
EIMonitoring Recovery ft. 1 ft. chip
Injection Well:
it ft.
apAquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
®iAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
IIIJAquifer Test IStormwater Drainage ft. ft.
®:Experimental Technology E3 Subsidence Control ft. ft.
*Geothermal(Closed Loop) (Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
i Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks)
O ft. ,t-p ft. CI ttu j /d ve-J 61 ,r e -1,
4.Date Well(s)Completed: ter-i'-Z3 Well ID# 5 .ft. / O ft. el ran i.-C
5a.Well Location: R. [ R. lt�
LQohOad lug ft. fI.
Facility/Owner Name Facility ID#(if applicable) ft. .,--� d
R. '��J
��.; Y ate.
/1)0 Sims Ea_ -r S G oLf Rd Is item Ili,i ft. ft. J U ti 2 C.1 2023
Physical Address,City,and Zip //�� Z 8 geZ q ft. ft.
BliJINC'OIN•.1o.€- "l7(,)I aim( 2- 21.REMARKS ;EFC..-<-.'i"n?rk\^tr:tyfg L1riY..
County Parcel Identification No.(PIN) D�+' 3 L1k
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
- S° 1401 1.5Z11e l'N SZ° 29 13G, Sig(e(02 I W
6.Is(are)the well(s) ermanent or Temporary
ignature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or Cr o with 15A NCAC 02C.0100 or 15A 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 this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT 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: 01- (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 00'and 2@100') construction to the following:
10.Static water level below top of casing: 00 (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: 6. 2,S" (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
n above, also submit one copy of this form within 30 days of completion of well
O `
12.Well construction method: 1 r�, construction to the following: I
(i.e.auger,rotary,cable,direct push,etc.) 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) gull. CIsending(Q�7 Method of test: t7Yl iriQlt 24c.For Water Supply&Infection Wells: In addition to the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: (I/1100'2 Amount:4 I b S. 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