GW1--06146_Well Construction - GW1_20230922

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WELL CONSTRUCTION RECORD(GW-1). For Internal Use Only:
1.Well r ormatiolu} / e •17 14 WATER ZONES i -
FROM TO DESCRIPTION> rION
/&Oft
NC Well Contractorrion Number IS.:OUTER.CASING(for nmit edtvdls)OR LINER fd • )
FROM TO DIAMETER THICKNESS MATERIAL
�y.S OIt. g� ft in. 'VC—
Company Name / F
)/V o� � •16::L4HNE]i:Ceti$113G�f3R:TlJB (grstlse�at dmrd-leap)
2.Well Construction Permit#: /y ✓ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits i.e.UC,County,State,Variance,etc.) •/ V I /� f 1D.
rl ft in.
3.Well Use(check well use):
Water Supply Well: 14.7ioSGREEN` DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultrrral DM Lpal/Public ft' ft in.
Geothermal(Heating/Cooling Supply) - Residential Water Supply(single) ft m.
Industrial/Commercial OResidential Water Supply(shared) -
Irrigati0n FROM TO MATERIAL EMPLACIEMENT METHOD dc OUNr
Non Water Sa Well: /���` n //__s e
PPIY V � 9t7 � �d'� 1�'l'� d b Ll/1 4 e
Monitoring 13Recovery ft ft
Injection Well:
ft ft
- Aquifer Recharge • OGroundwater.Remediation
, 19..SAND/GBAVELPACBf¢gPp le),
Aquifer Storage and Recovery 0 Salinity Barrier FROM T MATERIAL EMPLACEMENT METHOD
Aquifer Test' DStormwater Drainage ft-
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) DTracer ^:28:DRIL.LING.LOG.(attachadditeaaalsbeets:ifi eeessary)
Geothermal(Heating/Cooling ) Other(explain under#21 Remarks) FROM TKO} D N(tabu,Lars mahocrc r7ne grain�e era)
d n0 ft / 1N�
O 4.Date Well(s)Completed: 5/ J/ 23 Well ID# 8"1) ft. (61-5es ft. ,/ eiA•
5a.Well Location: ,'ft
fll, /(ez41i5 K.:r.-
FacHity/Owner Jame Facility ID#(if applicable) ft ft '" "' '' °'®":
Ore et rJ /1 ft. ft SEP 2 2 2023
Physical Address,City,and Zip ft ft.
t in .:21.,REMARES . .. . ....'-...."7....."_ ,,rw
Vvv LiJL•�
County Parcel Identification No.(PIN) '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _
(if well field,one lat/iong is sufficient) 22.Certification:
N w 1/ cle/e�3
6.Is(are)the well Perm s) anent or Temporary Signature of Certified elYContmctor Date
By signing this form,I hereby terrify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or Es
. No with ISA NCAC 02C.0I00 or 13A NCAC 02C.0200 Well Constrnc ion 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 wider#11 remark section or on the back of des 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 ne cncsary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /�-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-3Q200'aannd 2@1000 coon to the following
10.Static water level below top of casing: ! (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing use"+^c• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: ) 24b.For Injection Wells: hi addition to sending the form to the address in 24a
12.Well construction method: / g•(eV-7 above,also submit one copy of this form within 30 days of completion of well
nst(i.e.auger,runny,cable,direct push,etc.) won to the following:
Division of Water Resources,Underground Injection Control Program,
• FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service,Center,Raleigh,NC 27699-1636
13a.Yield(gpm) iS Method of test 4—7' 24c.For Water Supply&Injection Wells,: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
136 Disinfection type: T if Amount ��L 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