GW1--00355_Well Construction - GW1_20240112

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WELL CONSTRUCTION RECORD(GW-1) ' For Internal Use Only:
1.Well Contractor Information:�io PLJi(-a-r 1rto e
:14�WATER�Z07YES.�,'�.�..ia.r,�._ K 4-
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
SY SA ft. ft.
NC Well Contractor Certification Number ::iSIIOUTERIC"A'SING1(fo`Trmdlti+cp's"ed well`s)SOR'I INEIL(If<ap 7leible) x ::..'
--
(.4y // 'Pump //D' , �4G • FROM TO DIAMETER THICCICN�ESSSj MATERIAL
�+"n (% C J J ft. 7/f ft. /..t.,-In. 5l�Rot) 19{'t i
Company Norm I t t r ,ru_. .
) — � � 7 3 '16INNER'Ce1SWG.ORt-'LUBING;(geottier"iuelsCloseil=loop)
2.Well Construction Permit#: 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 1 Well: M1 SCREEN^ �*q< s s ;.;a 'e .: ;
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. In.
In.
Geothermal(Heating/Cooling Supply) t5?'Iesidential Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared) ,,IS%GROUTr r ;{s"P€s k 'VOW` ..Y z v W. '
_ _ _ 'Irrigation FROM TO MATERIAL EMPLACEMENT"�ETHOD&AMOUNT
Non-Water Supply Well: (9 tt., '} rt. f )1�P l (E O�Gti-e. - ��.ljG(C�S
Monitoring
Injection Well:
Aquifer Recharge Reeovery •
ft. !� ft. ` �J
ft. ft.
Groundwater Remediation '49iSAND/GRAVEL;PACK(If appllcable) fir,
Aquifer Storage and Recovery
Aquifer Test Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Stotmwater Drainage ft. ft.
Experimental Technology - OSubsidence Control ft. ft.
I
Geothermal(Closed Loop) Tracer =.;20:DRII LING LOG(uttaon-addmonal sheets tt necessaty)�
-
FROM TO DESCRIPTION(color,hardness,sollfrock type,•rain size etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) I I
ft it. r72/ EL Ji rl" G i7 a retie-i m-i X
o�-3 Well ID# 75-fft. 1�.�t'it. I�Y.� )
4.Date Well(s)Completed: ��-vim' / ``�J _
5a.Well Location; r -if- ft. ft. ;`1,%-( ,A---,bT A f6..a r"'h,
Thoi�aS J/
ft' ft' , JAN 1 4
Facility/Owner Name FagflityID#(ifapplicable) 2�24
/Lei uln ar ID r, ft.
Physical Address,City,and Zi ft. ft. I}YV•is t; x
/RiA /i e r n r`d s,2.1:,REMARIGSMT?:. 7,_ :-:i zk<_ s 4. '
County Parcel Identification No.(PIN) _
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ;
(if well�field,one lat/long is sufficient) (7sufficient) / 22.Certification::
3,5" 4 y 1 q0 N '- Z)o2-r 0'f/Q3 W g/Pt ✓lpi(- /- oZill
Signature of Certified Well Contractor Date
6.Is(are)the well(s) rmanent or Temporary
By signing this form,I hereby cerlfy that the well(s)was(were)constructed in accordance.
7.Is this a repair to an existing well: fjYes or No with 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known svell construction information nd explain the nature of the copy of this record has been provided to the well owner.
repair under#21 reinarks section or on the back of this form.- 23.Site diagram or add[tlotial 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: 'T Otg_5' (ft.) 24a. For All Wells: Submit!this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@20 and 2@I00') construction to the following:
10.Static water level below top of casing: /.& 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: l.1K (in.) 246.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: P/ / V 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: t 1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) 6 Method of test: /i/r 24c.For Water Supply&Infection Wells: In addition to sending the form to
n the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Gl11,Y I 11 8.- Amount: - 6a-n✓L 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