GW1--06926_Well Construction - GW1_20231027

1.Well Contractor Information: • l' 3 + i
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We1lConttactarNemc FROM TO),�y DESCRIPrKT , j
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NC Well Contractor Certification Number
•l OUTER:CASING(fo'rmMU:aiedwelli)ORLINER(ifal"m):R.!I-A L:.x.:: ';;.
hti i / J/ )pii /A FROM TO DIAMETER I THICKNESSSSSMATE
ft j23 it. iu ' fI ( UPJ �-eGCoyName
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/ •16:11iNER`CASS1NGOR:TUBING:(aliitliennidclnsed:lnop)1•:ir ;:;..?1::5:it:;:f• ' •;`.rig
2.Welt Construction Permit#: l/Y.f, 0 for 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. V � ft. In.
Water Supply Well:
h i17.SCREIsNIe;:...... rt're ^ ;cti;'::::_:.'c ?i3:,: i:it:: '` ::
•
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL ;.,
Agricultural DMunicipai/Public •• it: ..Att is
Geothermal(Heating/Cooling Supply) residential Water Supply(single) f in.IndttstriaUCommercial Residential Water Supply(shared) V xl&GRGUTr.'=;St''_
f.i+•%•. !:::':�•.i ...-:iiei. • " 0Zziiti i:r ;•;i .`1
. Irrigation FROM TO MATERIAL EMFLACEMENrMErHOD&AMOUNT
Non-Water Supply Well: ft fa
MonitoringPP Y � : ,� �E���AA/�� � � .�. rY
Recovery ft. ft � 1+ +I,i
Injection Well: ft. ft.
AquiferRecharge �Grotmdwater Remediation
:19:SAND/GRAVELPACKfdapplicable�':... :�.wc':: iE'"':c :::z:?= :a:':-:?J.
Aquifer Storage and Recovery IDSalinityBanier FROM TO TERU�L i EMPLACEMENT METHOD
,.,
Aquifer Test OStormwaterDrainage ft.
(�L
Experimental Technology 13SubsidenceControl ft.
Geothermal(Closed Loop) Tracer 20.'DRILLiNG LOG(attricfisdditiiiunlaheeillnecnsary)' = ,'?::.,.. ..1:i...;3>'
_ Geothermal(Heating/Cooling Return) f Other(explain under#21 Remarks) FROM To DESCRIPTION, oTer:ttardaess.aaar oektrFe.Kraras�eta)'
f r 4 . Vft. !Y,'1., .61/TU
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4.Date Well(s)Completed: !�`�'e�.9 Well ID# C ! y� 1 p�} �)� �/
Sr -)iLArrt;nn__ . t4.3 ft i` `. .).. f!!/✓II,lJ! $/Y,7
r o, -10 ip,,,) ) f ft. ft. ' 'II / �
Fann ty/Ow/nerName _mid /��, FacilityjlDfl(if applicable) ft. ft.
LAL!� 11?fI' .5: (Ai e4,ed li I // f. it --.'•':-�' •-'',F-7`:1, T,
Physical AAddresss..Cftiy,annddZip ' �/�// ft. ft. ` v' "r...' ,r: �r�r A, I '
l/ f�l/l yf i- • s21:REMARKS:t•,.,S13 i::'' .Z.At+•e..__.........'!•:....�•?rtt r t
County • .ParcelldentificationNo.(PIi� Cj, s �� "
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I n v7 R:" ?�• ^.g.; js;: f:
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ifwellfield,onetat/lonsufficient)is D `,_1•`
35, q %9k)e`' N /7,//),75 � 22.Certilicatioa: , i„�"2
6.ls(are)theweit(s) rmanent or jTemporaey Signature Certified el[Contractor : Date
By signing this form.I hereby certify that the wells)was(were)constructed in accordance
7 Is this a repair to an existing well: DYes or Lorci with 15ANCAC OIC.0I00 or 1SA NCAC 02C.0200 Well Construction Standards and that a'
Jfthis is a repair,fill outknown well construction information and explain the nature of the copy ofthts ic cord bar been pro vtded to the welt owner.
repair under#2I remarks section or on the back ofthisfo rot. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the backof this page to provide additional well site details or well
const uction,only1 GW-1 is needed. Indicate TOTALNUMBERofwells construction details.You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS 1
9.Total well depth below land surface: (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple welts list all depths tfdierent(example-14200'and2Q100) . construction to the following: •
10.Static water level below top of casing: 3 3 (ft) Division of Water Resources,Information Processing Unit,
Jfwaterlevel is above costa%use'• 1617 Mail Service Center,Raleigh,NC 276991617
11.Borehole diameter: 7 )in.
( 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
J/t © r.P above,also submit one copy of this form within 30 days of completion'of well
construction to the following:
(i.e.auger,rotary.cable,direct push,eta) / .
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: ) 1636 Mail Service Center,Raleigh,NC 27699-1636
132.Yield(gpm) 18P Method of test:PIP A-i�'ty• 24c.For Water Supply&Infection Wells: In addition to sending the form to
91A1g the address(es) above, also submit one'copy of this form within 30 days of
13b.Disinfectiontype: Amount: /O 1)Z completion of'well construction to the county health.department of the county
• where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016