GW1--04766_Well Construction - GW1_20230724

VV'. tiLL',LuPl'tlaIitt.JL.11LJ1V 11..UL.'1916dl For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: •
14.WATER ZONES
1���`n beA\C. e G�‘n ,3 (�. et FROM TO DESCRIPTION
Well Contractor.Name. t IS ft. ft.
•"1 0 3 to ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER gala-Rlicab►c) • '
FROM TO DIAME R THICKNESS I MATERIAL
\- J\\•% -A b r`\\\\ n C,. •-4-\ ft. 1-�Fj ft. ( e in. t i Zs- ?v c.
Company Name 16.INNER CASING OR"TUBING geothermal closed-loop)
u FROM TO DIAMETER THICKNESS MATERIAL
2 2 2.Well Construction Permit#: - �l -- ft. ft. in.
List all applicable well construction permits(i.e.County.State,Variance,etc.) ft ft. in.
3.Well Use(check well use): 17.SCREEN '
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) feResidential Water Supply(single)
ft. ft. in.
0Industrial/Commercial 0 Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL e EMPLACEMENT METHOD&AMOUNT
❑Irrigation 6 ft. 20 ft. leirlar't Ile
poor-
' \`
Non-Water Supply Well: Y
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge . 0 Groundwater Remediation 19:SAND/GRAVEL PACK(if applicable) . . .
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery OSalinity Barrier
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets ilnecessary) ' : '
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soilfrock type,grain size,etc.)
OGeothermal(Heating/Cooling Re m) ❑Other(explain under#21 Remarks) O ft. 10 ft. rt°A C. `, 1
4.Date Well(s)Completed: - i q�3
IV ft. /� rr. .- fyl `��
5.Wellft. ft.
_Location: ! , ��c. 2 v®ft. b i -4 5- (4t7r'r
16
1 I-% y 5'�D t/er- �l�dti i•-) .) ft. ft.
Facility/Owner Arne Facility ID#(if applicable)
1 ► r rr ft. It'-:
S? t•\e, r'1«y \.Lk c c.y (\1 c ft. ft. E f f ;
Physical Address,City,and Zip I �,�e ��
21.REMARKS .
Un i�c,n os --bLkQ-m4A JUL 2 4 2023
County Parcel Identification No.(PIN)
Inform Li-';1 Pr,._..a-_:_
4
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: D+,�fit�Jt�*. W, l i d'
(if well field,one lat/long is sufficient) 22.Certification: t �
314,6Lt Z N 6301 iii636 W /hi �e 0 ''-)/ 3.
Signature of Certified Well Contractor Date
6.Is(are)the well(s): lliePermanent or ❑Temporary By signing this fbrm,i hereby certifi.,that the well(s)was(were)constructed in accordance
with I SA NCAC 02C.0100 or i5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or l$No copy of this record has been provided to the well owner:
If this is a repair-,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this Prim 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: I construction details. You may also attach additional pages if necessary.
For multiple injection or iron-water supply wells ONLY with the seine construction,you can
submit one form. 24.Submittal Instructions:
>>�� /
9.Total-well depth below land surface: F.
7in
® (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@200'and 2@100') construction to the following:
'- r
10.Static water level below top of casing: 2 (ft.) Division of Water Quality,Information Processing Unit,
![.water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: ,6 f l€ (in.) 24b. For Injection Wells: in addition to sending the form to the address in 24a
• above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: K.ITYG�C �� construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: i 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) V Method of test 24c.For Water Sunnlv&Geothermal Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13h.Disinfection type: 147 'l4 Amount: 1 1 { ✓1 . completion of well construction to the county health department of the county
where constructed.
Fonn GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013