GW1--07781_Well Construction - GW1_20231201

WELL CONSTRUCTION RECORD (GW-1) For'Internal Use'Only:
1.Well Contractor Information: 1
h 1t 1 o S eSee.5 s 19:,-AYATElt'ZO'NES.;.�, 51,M ' "x;��Lrrgrs�ev^P,�*�`:,�s . r._.)_
Well Contractor Name FROM TO DESCRIPTION LL
ft. ft.
4I Pr
ft ft.
NC Well Contractor Certification Number --
15.iOLITER'CASING ai tiligeg Tegfi)ORTIl�IER(itisialcabrO "'.•'
J rA^ 1r (r �/ FROM'�V�S dN ' 'n,t �� FROM
TO DIAMETER THICKNESS MATERIAL
I•` ft ft. DIAMETER
in.
Company Name �_ :_ L
tWINNFR°CASIXd ilIkIHftirdirnWtt aircia eailo:4") `, `3 ,_,
2.Well Construction Permit#: 3I 3a3—S kycl@ CO. FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County;State,Variance,etc.) + d.... ft. 4 co ft. 9 in. 5e./ go r►/r
3.Well Use(check well use): ft. ft. in. V
Water Supply Well: 17.'SCREEN.,::f` ,... _.: f�?` i;r,} -Wri ,,r.--�.�: �` ,;r
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 2 4 D ft. a 55 ft. Li ,in• rJ 5.) „!u kvire.
Geothermal(Heating/Cooling Supply) Ofesidential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared) ;I8,GRouT; ' 7 tr ;= -* t,Vz",s ti„ s , :` tit Y, ;,k ,c i ,
•
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. g0 ft.
C e a utT ,.
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge • °Groundwater Relnediation
19::SAND%GRAVEL-PACK(if applicable) A.,• .s r+cS''w,;i str;"x*r 5-.
Aquifer Storage and Recovery oSalinity Barrier FROM TO MATERIAL EMPLACEMENTM� METHOD
Aquifer Test DStonnwater Drainage a 3 5 ft. PS5 ft. sea, #.2 Pour
-
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) 0Tracer . :20t'-DRIi1 ANG I OG{afiachtdddiHoriel's`liei i[neces'sar"y) ; M., . '
Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION(color,hardness,soil/rock type,strain size,etc.)
( g/ g Other(explain under 1121 Remarks)
ft. ft.
4.Date Well(s)Completed: I O—aS—a7 Well m# ft. ft. .
5a.Well Location:
a 31 ft. ass' ft. 01..rk
e_O )11,..'Mow ' ft.' ft.
Facility/Owner Name Facility ID#(if applicable) - ft. . ft. 1 4"--"'
- u {_,�
L0+' 41 LtJ&4ertNti L4,u), I tiel a ro `.
Physical Address,City,and Zip ft. ft. •
D r r 1 2023
Ny J G 1::RENtimcs';:,. ... -. ,,,A.;u- !.j? 4,.: w, r a m
County Parcel Identification No.(PIN) tfi r a l�E
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3 5 39 '13 N -7 6 11 a5 W I , 11—?v—.23
6.Is(are)the well(s) rmanent or OTemporary Signature of ertified Wel ontractor Date
By signing this farm,I hereby cent fi,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or g 1'o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair;fill out known well constriction information and explain the nature of the Copt•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 sameYou 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 necessary.
drilled:
SUBMITTAL INSTRUCTIONS;
9.Total well depth below land surface: a.Sc." (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-S@200'and 2@I00') • construction to the following: i '
10.Static water level below top of casing: . (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 diameter: / III (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
,Q .,/ above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 1� f�f construction to the following: 1 '
(i.e.auger,rotary,cable,direct push,etc.) -
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) a '�n/D Method of test: Yvtvt✓1 24c. For Water Supply&Injection Wells: In addition to sending the form to
�I" the address(es) above, also subttiit one copy of this form within 30 days of
13b.Disinfection type: )"ITh Amount: lilt. completion of well construction tb 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