GW1--00309_Well Construction - GW1_20240112

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Co tractor Information/:
'...1 FROM TO DESCRIPTION
Well Contractor Name
ft./ [J� . ft.
//
7 y `7 4 ft. ft.
NC CertiificcJati n Number
//��1/ / /^ 15 QUTER`CA$1NG(for tntiltl�cased)w�ells):OR=G1METER hN/E�R-(flap noble),f/
/`G��/(JI,J vt/�e G( V Man, �.U./ ..I- (`G FROM
yM rt.
T 7q fL /O A /-47'n' S DR,,z)KNESS MATERIAL
Company Norm �/�/ J �/ L/ 16.1INNER GAS1NG_OR T BrNG:(geothermalicloaed=loop)
2.Well Construction Permit#: yi``.-t�D(O /0 /� T FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County,State,Variance,etc.) It ft, In.
3.Well Use(check well use): ft. ft. In.
I Well: 17.�SCREEN
Water Supply Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipaVPublic ft. ft. In.
Geothermal(Heating/Cooling Supply) EgResidential Water Supply(single) ft. rt. In.
Industrial/Commercial OResidential Water Supply(shared) -,Ig.GROUT-'
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft. !'q ft. Ze/i/E1C-' )uY1I1)PA - r45 bazi
Monitoring Recovery ft. ft. v
Injection Well: ft. ft.
Aquifer Recharge }Groundwater Remediation 19.$AND/ RAVEL.PAQ'K-(Usrjpplleable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test • OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer -20:DRILLING LOG(attach additional:sheets if necessary).
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DescRiPTlory(color,hardness,soturaak type,ousts size,etc.)
p ft. / qft. c I k y
4.Date Well(s)Completed:12,--/6-23 Well ID# D U ft. ,,,ZZ.t,-t' �{rcZ ytl t.
n. ft. J ��
Sa.Well Location' , I`k 1:(. �,,� j (.
Facility/Owner Name / Facility ID#(if applicable) ft. ft. jN�V j ,
2024
C J 7 )9r; "/6c- A Rd . VdfL q 'r `"—g ft. ft. lrl�Vil7- f 'fir-.r✓ :£1 r ..9ti�ils 1 UtC1
Physical pddrass,City, d Zip 5 ys
`J -21.REM1 ARKS _ Cu-" 7 �j
County
LL LZW Parcel identification No.(PIN) . _ 1. r i A Y1 L t- N 0. ,�M ) r�'// U
ry
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees: -
(if well field,one lat/long is sufficient)( �) ) 22.Certification: 1 / c�
/j A-, 1p 3 Z ��L O N ^ b ( t 4 7'/ �q�U W > �i�-!"L) 4-
/(41-44-1: /'d' -a D,; 16.Is(are)the well(s) Permanent or Temporary Signstare of Certified Well Contractor Date
By signing this form.I hereby cert(jy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [jYes or ENo with!SA 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 well owner.
repair under#21 reinakr section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Ihdicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2 6 3 (ft.) 24a. For All Wells. Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3t200'and 2@100') construction to the following:
10.Static water level below top of casing: vC.0 (ft.) Division of Water Resources,Information Processing Unit,
1f water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 7-4- (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: r D fix r y
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,etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: i 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) I-- Method of test: 6 ./K1 24c.For Water SUDDIv&Infection Wells: In addition to sending the form to
ll� ) (/< the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:..(-'-Yh 16 ill✓l€. Amount: . )x - 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