GW1--07805_Well Construction - GW1_20231201

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Jim!1 f teSAe55 `.14:.WATER•ZONES. '' ' •,;r .. .. _. . .
Well Contractor Name r FROM TO DESCRIPTION
ft. ft.
gill il- ft. ft.
NC Well Contractor Certification Number 15..OUTER CASING(for multi-cased}`wells)OR•LINER'(ifap-livable) '
r rr FROM TO DIAMETER THICKNESS MATERIAL
SD 1"tet�Senn Of( tItc,'` U ft. `70 ft. 30
in. e 37J S l�
Company Name JJ "1
d6:;INNER:CASING OR TUBING(ieotL'ermnl eiosed-loap) . y-.-•
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County State,Variance,etc.) ft. 1 f_fi ft. /'1 D in. 3 75 C 1___ j
3.Well Use(check well use): et. 1 t7 O ft in 7 J JQ-(
Water Supply Well: 417:`SCREEN ,; -,. ,•. -_i :: . ..: , ...+ .- .-
FROM TO DIAMETER . SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public /61' ft. _(,eft. _
Geothennal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. oi,
i/ A'
Industrial/Commercial 1 Residential Water Supply(shared) =;is:GROUT. i 3 L r. E I , d1 ;r
w.:, S•t..::
Irrigation C we e.r FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. *�' ft. Celn,e4.f (/Jv`y�
�
Monitoring Recovery ft.
Injection Well: 4 I IA, ft. l�f .4P i
pc,vLl
ft. ft. 1
'Aquifer Recharge DGroundwater Remediation -
.'19:.SAND/GRAVEL PACK(if applicable),,`.:. '->- r
. Aquifer Storage and Recovery Et Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ligiStormwaterDrainage ft, ft.
Experimental Technology D Subsidence Control ft. ft.
Geothennal(Closed Loop) VI'Tracer 20:^DRILLING LOG:(attach.additional sheets:if:necessary)
FROM TO DESCRIPTION(color.hardhesi,soil/rock:type,iiriin sife7t1r.)-,,
Geothennal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. ft. • k ri } y y ,t t_
4.Date Well(s)Completed: 11- Well ID# 33--0O I ft. ft. n:r 4 1 2023
5a.Well Location:
ft. ft. t ,
ft. ft. Ii:w,tip4-.:+! !":..!7.;L�;n'.5J j.i:'i t'�
Facility/Owner Name Facility ID#(if applicable) r S 0ft. (9 GO ft. I- i v,,te. tie
IS3o uL `3b(,S a�i606 ft. ft. .
Physical Address,City,and Zip ft ft _'-i` . 4
df/�'(1!,-�•`� •(�� lT— ,Zl'RElYTARKS_,L:�.. ..'r�< h {`^,.._. ,a.�'�r",t-.Z4-.414^`MAWvi» k:
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
"SS I `),q4 17(03 a N `A6. ENTZ633 u W • ( ( n•-al-a3
6.Is(are)the well(s) Permanent or iTemporary Sigma ure of Certified We Contractor Date
By signing this form,I hereby certif-t•that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or `o with 1 SA NCAC 02C:0100-or I SA NCAC 02C.0200 Well Construction 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 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 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 necessary.
drilled: rr��//�jSUBMITTAL INSTRUCTIONS •
ec 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-3@200'200'and 2 c 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"� p-1" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: cx D (in.) 24b.For Iniection Wells: In addition to sending the fonn to the address in 24a
��,pp l above, also submit one copy of this form within 30 days of completion of well
@l
12.Well construction method: b T41r? construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,4Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) }500 __ Method of test: 119v tme 24c. For Water Supply& Iniection Wells: In addition to sending the form to
the address(es) above, also submiti one copy of this form within 30 days of
13b.Disinfection type: 1-n- f'1 Amount: 5 I(IS- 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 •