GW1--04798_Well Construction - GW1_20230721

FY EALAIL.'L.t.MJ.'I0 I/M V v1..I I JJ.'1 ivt:,u..,vaw For Internal Use ONLY:
This form can be used for single or multiple wells
1.W Contractor Information:
C1 ha•CA �/�1 1 I I,S 14.WATER ZONES . . -
` ` 1{1 I FROM TO DESCRIPTION
Well Contractor Name; {v�111 {i _Ott. l�C%O ft. �\��� 51® _`�iI O a3p„„
CAS V yi 1Ltia t. 4 1 oft. pt(� m A 'A„
NC Well Contractor Certification Number 15.OUTER CASING(for multi-case ells)OR LINER(if up licablc)'
_ FROM TO DIAMETER THICKNESS MATERIAL
ERIAL
`D,L. Mu_111, Wed lbr.111 :L nc. ft. ft. Up'19 in. „ 10) V
Company Name '16.INNER CASING OR TUBING(geothermal closed-loop)
11,, 11 rr /�^ ��}}�� FROM TO DIAMETER THICKNESS MATERIAL
Z.Well Construction Permit#: CA - �J G a�VOI b�a,Jl 1 .i- I ft. 4 8 ft f _e 1 Is in• ' I a s `�v c
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 ❑MunicipaUPublic
❑Geothermal(Heating/Cooling Supply) R esidential Water Supply ft. It. in.
( 1� g PP Y) PP Y(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Inigation Non-Water Supply Well: it
ft.'a� i+C TotAre!il
ft. ft.
❑Mott itoring DRecovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier rt. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach'additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color, ardness,soilfrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. O ft.
` `p�� I C l�
(� ry 3o rr. Q ft*
V ,� 1+�n
4.Date Well(s)Completed: b c ` a a)3 "1 ]7�p ' a-
5.Well Location: Lin ft451-
,Sl, Oft �e, �„ 1,,
,. ft. ft �l�
—Frit-Ann Love- ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. • ft.
__11 NtUh.R®F
T�auner r �l U 1 .r rL ft. ft.
WLlio t5
(I steal Address,Cit id Zip ) 21.REMARKS J U L ;i j 2023
-JcL.b&rri,I,' ,: -_.. _.. rB:%':Cv ___ „_
County Parcel Identification No.(PIN) DWQMOG
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 r. ation:
(if well field,one lat/long ist sufficient) 1 1�y c,f L I
&5.• 0at/1 1 1 N c L
0• i"1 5 o W f I(�(l G'' 6-6-2
Si ature o Certi ed Well Contractor Date
6.Is(are)the well(s): kermanent or DTemporary By signing this form.1 hereby certify that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or l'lo copy of this record has been provided to the well owner.
((this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section of on the back of this_Pro'. 23.Site diagram or additional well details:
I You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. �' I /� 24.Submittal Instructions:
5t_j 0
9.Total-well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii different(example-3@200'and 2Q100') construction to the following:
10.Static water level below top of casing: t U (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
ff -- 1
11.Borehole diameter: l_P dt (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 m G� L( construction to the following:
(i.e.auger,rotary,cable,direct pusli,etc.) J
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ) Method of test: r6 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
, `-y-' 1 ` the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 141 4 Amount: U p‘nTS completion of well construction to the county health department of the county
1 where constructed.
Fonn GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013