GW1--00264_Well Construction - GW1_20240105

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only. MillalTil
1.Well Contractorrmation:
tcC 151e,rc ,IVIS
Well Contractor Name FROM OH
i 1 /� -rt. rt.
NC Well Contractor Certification Number
2,,u , t�\a W �, D r, \\; C\ l\,c FROM TO a. THICKNESS MATERAL
Company Name j ` t. 6" n 6 4 S D ‘ ►v .
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATER&
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft. ft in.
Water Supply Well:
FROM '© DIAMErEXt SLOT SIZE THICKNESS MATIRML
DAgricul u al OM cipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) iden
tial Water Supply(single) ft. ft, In.
Industrial/Commercialidential Water Supply(shared)
nIrrigatian FROM TO MATERIAL , •.`i A` :•, r
Non-Water Supply Well: i ft. ;j),v ft' Q_,G,n<f�'re 1 ‘0" 5 E' S`' I b
Monitoring ['Recovery ft, ft. U•
Injection Well: —
ft. ft. IIIIIIIIII
,&
DAquifer Recharge DGroundwater Remediation
ss Aquifer Storage and Recovery ['Salinity Barrier �� EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
•
1111110161111
Experimental Technology Subsidence Control ft.
OGeothermal(Closed Loop) DTracer •
['Geothermal(Heating/Cooling Return) ['Other(explain under#21 Remarks) FROM TO DES I TIox(al.� .wtnet Rim gal.fie,err
4.Date Wells)Completed:`k m �S J 1 Well ID# 66 ill' aY o v `a„... ` -
5a.AVell Location: 2-5(L ft. n' ' CJc f/4';ce-- .l 5 inn
, 1.6
3
Facility/owner Nwo Facility ID#(if applicable) ft. ft.
11 04 i22I ft- ft. '4 0 s ZOZ4
Physical Address,(1ny and zip n ft. ft.
O o�tS 'Oh 7 '7i4(.-679•i4aS-3
Catty Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W , N.c��(Zr^ V O I ' j [ 3,'
0
6.Is(are)the well(s)OPermanent or Temporary Signatmeef Well Contractor Da4 i
By signm4 this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or [PTo with 15A ATCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out brown well construction infonaation 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 5 ♦v 5 (ft.) 24a. For All Web: Submit thin, form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2®100') constnwtion to the following:
10.Static water level below top of casing: ' 2, 0 (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: ) 24b.For Infection Wells: In addition to sending the form to the address in 24a
�- above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 0 r�'' construction to the following:
(ie.auger,rotary,cable,direct push,etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources, Underground Injection Control Program,
1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 ' Method of test: \`% 24c.For Water SADDIv&Infection Wells: In addition to sending the form to
7 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: !. 2', • Amount: � lo e - ' 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