GW1--04904_Well Construction - GW1_20230728

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Co tractor Infor ation: -
AYre:. /0G_.s� 8 I/ _ 614.WATER,ZONES> .. .. S : ,;,- ; :.si,2 ,. ...,
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
/''
p1
'/ 2`J -A ft. ft.
NC Well ntmctor Certification Number /1 '1'StiUDTER�CASING(fotmultt=c6eed veusycno;INERi(i[:ap Beable)
FROM TO urns ' S /)eJ) /r t 6 • J Le,. ft. /3 (�ft. �,Jam'°' Tht d I P I)Gu
Company Name . ,, :'.,
16.INNER CASING'OR':TIIBIN6i'( eothei�t+l closed=liioP) "
2.Well Construction Permit#: /© d c..5 FROM TO DIAMETER THICKNESS MATERIAL
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: ':17:"SCREEN, ,. ,-,:., @ t..,Y <.., .c ,.:.,. ., iii .. S t.-.i. .,-,
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS. MATERIAL
Agricultural DM cipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft. ft. in•
Industrial/Commercial DResidential Water Supply(shared) ;-.181:GROUT,i .%:1&:. ti' .. i..: : ?
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AM LINT •
Non-Water Supply Well: r) ft. {�6 f t. .h enlenI f 13 ill-r D D u rCz
Monitoring [Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
<19,SAND/GRAVEL:PACK°pfiappllcable)';r. . .:.< F'"r; _ .
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test D Stormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer :2WDRILLING L'OGi(attaeb?additional'eheeets'itneccasory)f ::::a .`a.'::. '.^_
FROM TO DESCRIPTION(color,hardness,saWroek type,grain size,etc.)
Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft cN a
4.Date Well(s)Completed: Well'ID# 14 O ft. f.CP• ft
j
v��-f�
5a.Well Location: ft. ft /
iY)j., i_e)le_ Ly niJ ft. ft. fay ;r7;1,•tr--
Facility/Owner Name Facility ID#(if applicable) ft. ft. s `k�.'J L I V L...
14046 e-04, p16QSaL-nt v/'e ) ft. ft. .i t i t 9, 8 71123
Physical dress,City,and Zip., ft
a :).21'REMARKS rj. z , ,„t:.rVitlw� r s+t t i ;: 'XC�+ti.::7,vt2x u'
County Parcel Identification No.(PIN) -
•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(if well field,one let/long is sufficient) 22.Certification:
2.3t 373Lg N ~ 22, oho 0I w ,e,A4 -- , 7_,,z4.-;.3
6.Is(are)the well(s) Permanent or DTemporary 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: OYes or No with ISA 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 nd explain the nature of the copy of this record has been provided to the well owner.
repair under#2I 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
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9.Total well depth below land surface: 4 6 (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 a@200'and 4)100) construction to the following:
10.Static water level below top of casing:' d (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: CV (i •) 24b.For Infection Wells: In addition to sending the form to the address in 24a
OD ate above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 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 27699-1636
13a.Yield(gpm) Method of test: rt-( V 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:A.)n Y I me, Amount: ,-2. G 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