GW1--06623_Well Construction - GW1_20231017

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contracfor Information: ,
liti•ed I V 11. &I�', 6QV In Cl CiCSOrN WATER TONES
FROM DESCRiPPTION
Well Contractor Name '10 it ft.
2C> 6 :r. 160 ft. ft
NC Well Contractor
�Cettification:Number IS.OUTER CASING(for multi-tasedwells)OR•LINER(flap &cable) • •
TO DIAMTER. THICKNESS MATERIAL
I Vkv 1\� \i`Q\ try \\ + M ft. S`Z ft. , e in. , ra C
Company Name
16.1NNER CASING OR•TIJBING(geothermal closed-loop) ' '
FROM TO DMMKFER TffiCIINFSS MATERIAL
P2.Well Construction Permit#: (j t+ -w E"20'23-©0111 ft. ft. in.
List all applicable well constnrcttan perntts(i.e.Countyt State.Variance.ate.) It ft. in .
3.Well Use(checkwell use): 17.SCREEN. •
Water Supply Well: +FROM TO , DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural DMunicipal/Public ft.
In.
ClGeotheratal(Heating/Cooling Supply) IDResidential Water Supply(single) R In.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT t;
FROM TO MATERIAL PLACEMENT METHODOD&AMOUNT
❑Irrigation CD ft 2.6 ft: • Artnonl�.e +pOUl''
Non-Water Supply Well: D l
ft. ft
❑Monitoring ❑Recovery
Injection Well: ft it
❑Aquifer Recharge OGroundwater Remediation 19.SAPID/GRAVEL PACK(if applicable)• •
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery oSalinityBarrier ft ft i•
❑Aquifer Test ❑StormwaterDrainage
ft. it.
❑Experimental Technology ❑Subsidence Cantloi 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION fplor,tinniness,unfrock type,grain size.etc.)
❑Geothermal(Heating/Cooling Return ❑Other(explain under#21 Remarks) C. ft l b ft ray d C., a V r
4.Date Well(s)Completed: _`a I b 12 l 6 ' 20. IL -rwTt e le-y ,
26 it 4100" Ikue. sk a ,
S.Well Location: ft. ft.
DONACk 1\2'4`J ft it s, _ s
Facility/Owner Name Facility KW(if applicable) -��I ' F
ft. ft.
LA235 4-.1r% . ce>V . 4 ft. ft. OCT 1 7 2023
Physical Address,City,and Zip 21.REMAIUCS i n` '- -.:;:7, .
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: 1
Of wall aoom 1ai/loag is sufSo:ene) 6 04 �%��b W r ,
55, �q Ch N
Signature of Cenified Well Contractor i Data
6.Is(are)the welil(s)://1Permanent or ❑Temporary By signing this form.I hereby certfy 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 ei1No 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 under#21 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: I construction details. You may also attach additional pages if neer¢sary.
For multiple tnftwtion or non watersupply wells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions: 1
9.Total well depth below land surface: 0 (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'and 2@100') construction to the following:
10.Static water level below top of casing: e,0 (ft.) Division of Water Quality,Information Processing Unit,
if water level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
/
11.Borehole diameter:• rJl3 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Ave- ve, also submit a copy of this form within 30 days of completion of well
12.Well construction method: •( Iran•r- construction to the following:
(i.e,auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Gontrol Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
.424c.For Water Supply&Geotheirmal Wells: In addition to sending the form to
13a.Yield(gpm) , 11 Method of test: the address(es)above, also submit one copy of this form within 30 days of
13b.Disinfection •e:'1 \ Amount: WI completion of well construction to the county health department of the county
where constructed. 1
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013