GW1--00269_Well Construction - GW1_20240105

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only. UMM711.1
1.Well Contractor Information:
Well Contractor Name FROM TO
ft. ft.
NC Well Contractor Certification Number
IR e AAA erg Ca 1 aw el 11 J( 't \l\ v\S \` n C. FROM TO Dla �CKNESS M A
Company Name
1t. '. R. (40 In. 0 i'.•1 C...,1 •
2.Well Construction Permit#: \ i 0 I d 3 4-c' S 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. ft. In.
Water.Supply Well: FROM TO DIAMETER SLOT srza THICKNESS MATERIAL
Agricultural DM blic ft. ft. in.
Geothermal(Heating/Cooling Supply) ' ential Water Supply(single) ft, ' ft, in.—
Industrial/Commercial ()Residential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: C, ft. -7".G ft. (-4 flt:A t t '2,0 h c,.c S e
Monitoring ()Recovery ft, ft. �- „ .j
Injection Well: Q \ •lht
ft. ft.
Aquifer Recharge DGroundwater Remediation
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL E CEMENT METHOD
Aquifer Test D Stormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) ()Tracer
Geothermal(Heating/Cooling Return) Other(explain under#21 Roma* PROM TO DESCRIPTION fealai '.alf `gab Jas..ac)
4.Date Well(s)Completed: a 3 Well ID# ft b O ft. ?�pL t/\ - /
I � ft. 11 ft. .-
Sa.Well Location:L 1 b t(,) Vc EN\Ce, —`� r- '
(\QQcC_ \7r i^ \k ft. 3 o Gi res--vNsi# — 3�
Facility/Owner Name Facility ID#(if applicable) ft. ft
t IA ft. ft.O i
\-1 C.O ccc 6c_.0(.1C1, _
Physical Address,City, Zip
tyke.,,,v rs CA 39\4C33.1-1 1
Parcel Identification No.(PIN) ICounty -
1
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees: N 0 ' 284
(if well field,one lat/long is sufficient) 22.C don:
3:5 34 I 60 rI S t e) ` A,! 0 '1 l i,�, n,rn„
N W ' t a3
6.Is(are)the wells) anent or Temporary S' o ell Contractor Date
Perm
By si is form I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or DNo with ISA NCAC 02C.0100 or ISA 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-sell owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional we]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: " '<- (�) 24a. For All Wells: Submit this firm within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: l (ft-) Division of Water Resources,Information Processing Unit,
If w ter level is above casing,we"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: `6) (in.) 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: construction to the following:
(ie.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS Y: • 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: �i J 24c.For Water Suooly&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: T-41 Amount: 1 Z O 1 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