GW1--06145_Well Construction - GW1_20230922

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contr ctor Information
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Well Contractor Name / FROM TO DESCRIPTION
ft. ft.
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• NC W II Contractor Certification Number r- ?1 ;OiQji([oiritill},',rEpredSwelleji01t1L+INk3It,(lf+4p"Uiible)h
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FROM TO DIAMETER THICICNESS MATERIAL
Company Nam !
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2.Well Construction Permit#: /- -#-/� /Jn�'/ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(I.e.UIC,County,State,Variance,etc.) ft, ft. I` in.
3.Well Use(check well use): •
• ft. ft is
Water Supply Well: �FR M� TO r. DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural °Municipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) )f2 Residential Water Supply(single) ft. g, i in.
Industrial/Commercial OResidenthd Water Supply(shared) if4YB:(GRU'<7,T,"` r,_:-,W,A g ... k rS2 z< <f,., .'.� .;,,;c;= ,_.;;: .
Irrigatioi "FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: (.9 ft, ;-..d ft• jj i 'n yi lie, 13 b. 4S !d),axed
Monitoring ' . °Recovery ft. ft. / I
Injection Well: - ft.
Aquifer Recharge QGroundwater Remediation
i191SANDASO E'LIPA♦;Iti(itFo'Aplcable) ,11,
Aquifer Storage and Recovery ' Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test \. °Stormwater Drainage ft.
Experimental Technology in Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer olIQ UIlI:INtSs,.I O.(Y(a(tielfldiUfiionsliiltee'thgltecetgory)n :: 'ir° ,;?,._. ..
Geothermal(Heating/Cooling Return) [Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,herdneaa,mil/rock type,grain size,etc.)
/) fa 9 q fr' I) a Am-L , GL%I"t
4.Date Well(s)Completed: q----i.---21 Well ID# /0 U ft. 1 ild fi' YQ-Yl/!C'_,
ft. ft. I.
5a.Well Location:
D;I1.e,n 1- cif) aL ft. ft.
t5er b ' D.S.,Mom �....
Facility/Owner Name Facility ID#(if applicable) ft. ft. I: f `C t I. V t k
1 5 2 S 11 'to RA, - `. ft. ft. 1 ,
Physical Address,City,and Zip ft. ft. I S C I' y 2023
h ()(LC 01 '21`REMARKS „ . , j;:.; `.�:! t' -' ...� Ut'
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County Parcel Identification No.(PIN) II i lest
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:• •
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(if well field,one 1at/long is sufficient) 22.Certification:
5 3‘1 C N I; ig 6.J w r 11 z'� C.JaAl'A q 6—1-5
fir'°Temporary Signature of Certified Well Contraoto/ Date
6.Is(are)the well(s) Permanent o
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 DNo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,Jill 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 I GW-1 is needed. indicate TOTAL NUMBER of wells construction details. You may'also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
1:
9.Total well depth below land surface: / v (it.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple.wells list all depths if different(example-3Q200'and 2@100' construction to the following:
10.Static water level below top of casing: ' O (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 diamt ter: (in.) 1.24b.For Infection Wells: In addition to sending the form to the address in 24a
�— above,also submit one copy of jthis form within 30 days of completion of well
12.Well construction method: y. Il /GI—Y'1/ construction to the following: t
(i.e.auger,rotary,cable,direct push,etc.) / S
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) d Method of test: Lt-I r 24c.For Water Sunni!"&Infection Wells: In addition to sending the form to
n 1� c ryry the address(es) above, also submit one copy of this form within 30 days of
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13b.Disinfection type: (-Nor,or,Ile Amount: oc- -1A/)Q completion of well constructions 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
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