GW1--06397_Well Construction - GW1_20231009

--— ..,sr a.avi.J.Vua.vttre. I For internal Use ONLY:
This form can be used for single or multiple wells
•
1.Well Contractor Information: j \i/
��,V n 1 ` .-� 14.WATER ZONES- . I ' -
1 ( t.—A!/I y+G(. iC C O n FROM TO DESCRIPTION •
Well Contractor Name g5 }t, I
'Z p b I OS ft. ft. 1
NC Well Contractor Certifica4ion Number * IS.OUTER CASING(for multi-Cased wells)OR LINER(dap licable) •
0 ` I Y\ A 5 Seri 1 br t u \`n FROM TO DIAi THICKNESS MATERIAL
1 �j +1 It. SO " 1 It 18 in. t as I)VC
Company Name 16.INNER CASING OR-TUBING(geothermal closed-loop)
FROM TO DIAMETER _ THICKNESS MATERIAL
2.Well Construction Permit#: • 202 3 — i 3 .6 • ft lw in.
List all applicable well construction permits(Le.CountO;Staten Variance.etc.)
ft. ft, in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/public IL ft. in.
OGeothermal(Heating/Cooling Supply) ifiResidential Water Supply(single) ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT " •
FROM TO MATERIAL • EMPLACEMENT METHOD&AMOUNT
❑Irrigation " © it ft •
Non-Water Supply Well: `Z® lea t\ b v,^e�
❑Monitoring ❑Recove ft. ft.
ry 1
Injection Well: IL it i
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(If applicable)
uifer Storage and RecoveryFROM TO MATERIAL EMPLACEMENT METHOD
❑A
9 g OSalinity Barrier ft ft i,
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
(Closed Loop) OTracer 20.DRILLING LOG(attaclimdditional sheets sary) '
FROM TO DESCRIPTION(color,hardness,sail/reek type,grain size,etc.)
❑Geothermal(Heating/Cooling Re ) ❑ ther(explain under#21 Remarks) Cr ft z 6 ( Gc.` y
y
4.Date Well(s)Completed: .."2- 2 lc) rt. b D ' c �/ r`Gbr1 C�)/
5.Well Location: ir/�/�- ® 8� f t Ai � t�
SGme3 Gs'c-►-t-'i-. .n �� ft \$� f. ��C S1a
Facility/Owner Name Facility Mil(if applicable) ft. r ' `.i'Yit yrt "'e
1 D-1 bxel•, Ln ft. ft OC I 0 9 2023
Physical Addres, ity,and Zip
k`1 L1639- tl 15-2 3 41 linli
21.REMARKSI - '-.
County Parcel Identification No_(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: Z2_Certification:
(if well field,one lat/long is sufficient)-3st ( 2 It-1 N4t2:70,CAO1/4
- W q i i 1 12 6
Signature of Certified Well Contractor' Date
6.Is(are)the well(s): liiliermanent or OTemporary By signing this form,I hereby cerhfy 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 Flo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair wider#1I remarks section or on the back of this form. 23.Site diagram or additional well details:
• You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 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 oneform. 24.Submittal Instructions:
9.Total well depth below land surface: I S® / (ft.) 24a."For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Qa 200'and 2®100) construction to the following:
10.Static water level below top of casing: .Z (72:0 (It) Division of Water Quality,Information Processing Unit,
e If water level Is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: te I S (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
k l above, also submit a copy of this form within 30 days of completion of well
,�
12.Well construction method: VLOTA`rs**1 - construction to the following: 7
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: x 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: C-- 24c.For Water Supply&Geothermal 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: RI. Amount:4 1 INcompletion of well construction I the county health department of the county
VA-
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality uality Revised Jan.2013