GW1--04800_Well Construction - GW1_20230721

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1
£ crre.'tt. ell Contractor Information:
Poi d9(% 14'.GVATERsZONES ,: kal:. < ... ,..r;r d ?{j; ,
Well Contractor Name V FROM TO DESCRIPTION
y5 y5�4 ft. ft.
ft. ft.
N Well Contractor Certification Number "
15`;OUTER:CASING"(for+meld cirreii wetis)lOR I;DHEIt'(it ap"llaable)` .:r;,. =
�� s Weil t; eln��p Co. sj DIAMETER 1PRIAL
- fq5ft. '- THICKNESS VC
Company Nam � !J y1'6:�INNER CASING�OR,TUMNGI eothe inaliclosedgoop)"s .,, _
2.Well Construction Permit#: 01
I- -'2 d z 3"j /1"f;,'� .O -1�j FROM TO DIAMETER THICKNESS .MATERIAL ._
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ) f f•
3.Well Use(check well use): ft ft in
".3177iSCREENIaf:?.yg g..:5s, ""??tei„a`. ,<4 `V .32:i fe. ::✓1.+.4'4iy 5
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
•
Geothermal(Heating/Cooling Supply) 111Residential Water Supply(single) it • ft. In.
Industrial/Commercial Residential Water Supply(shared) 11.'GROUT :us . .. ,v;:;' ,. . Y",i ; •. ;:
Irrigation FROM TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O R. 2%•° ft. &AVIV , /0 5c4d.s
°Monitoring °Recovery ft. ft.
Injection Well: ft. ft
Aquifer Recharge Groundwater Remediation
,',1WSAND/GRAVEL PACK(if'applicable)' r..: " ....,.s,,�;
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwaterDrainage ft. ft.
Experimental Technology °Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer t120-DRII,IsING'.LOG`(iittioli ddition>tl`elieets"ifiieceesoiyM • w 'sl
FROM To DESCRIPTION(color,hardness,sail/rock type,grain size etc.)
°Geothermal(Heating/Cooling Return) QOther(explain under#21 Remarks)
O ft -i5 ft. Clay
4.Date Well(s)Completed: !'( -Z 3 Well ID# q 6 ft. r 6 5 ft. &✓'an 1
Se.Well Location: ft. ft. ffi \C L e i t/PD
CIpt1JTtLr1 Nome.SlaSH AraPerkts JUL 1 `3
Facility/6Owner Name Facility ID## ft.
�(if applicable) ft.
W GS1 Yi Or. LO f'// ft. ft.. ft. In ^l)r��G/�O itarbiew,Ur,
Physical Address,City,and Zip
(,Cif 0wbG
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:
35.63472 N 'l.Y7395 w / !% -4/L•� �—/7-„-1-
6.Is(are)the well(s)EPermanent or'OTemporary
Signature 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: °Yes or No 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-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: /V 5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple.wells list all depths if different(example-3Qa 200'and 2®100) construction to the following:
10.Static water level below top of casing: 6.0 (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: C (in.) 24b.For Injection 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: A oht ry 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: A. 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 Method of test: A.1 Y' 24c.For Water Supply&Infection.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:r/'L IO rf Vi G Amount:IZsi.12 5 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