GW1--00438_Well Construction - GW1_20240116

.I.WWeejll Contr
/ac
cttor Information:
1 ..j 'i!6�A l 4j I _ i I
• a v �e)% Sf/ t(�^1�i/ f.l .1'4.1WATERZONES'... 'V;.. . tfr:.Pr, ,:_t,••, �i. •.r;.:• :1..
Well Con torName FROM TO D iCRIFrIIIVI /'' �' " <) G/
1>_ • ft. ft. gf Jli 14 4L /✓A.
r�/ ft. ft. J/ Q} ,t .
NC Well Contractor Certification Number �� ) ` v /�G ��3
J �/ Il OUTER:CASINGOafitulti:cafe`dwalls)ORLINER(M"'licable)7:F:: ::,•"•s,
�� ! C/ „ ��) ,5 , /� r FROM TO DIAMETER , THICKNESS .MATERIAL
CompanyName "r'!!! ft. f 1"( ft io. r, ,�I 7 ,
'] ) 416:I NEWCASS1NGOR:TUBRIG:((edtheemnliloied-leap)?:: :3>€t/t�.i•at,:':=,`:•i:'t;S
2.Well-Construction Permit#: < �� FROM - TO DIAMETER • THICKNESS MATERIAL
List all applicable well constructionp'ermity ti.e.DXC.Count::•State.Variance.etc.) ft. ft. In.
3.Well Use(check well use): /
" ft -
ft. in.
Water Supply well: .•17:SCREENS -..,<< 'vc; i;1 .F t;'>'<•Mg•I >it•,: - :; :
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
*Agricultural DMunicipal/Public - 0 ft ft in.ijf -
,Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft ft in.
;d'Industrial/Commercial E3Residential Water Supply(shared)
'jRi anon ::1&GROUTr.'�i?!e.:a; ;...s�?:` :;: :i3," ::. •9r: cr.:,•�?,.-: :;c:•:;:..,.;...
g FROM TO MATERIAL CEMENT METHOD&AMOUNT
Non-Water Supply Well: f") ft l 7 ft. / f y/j/ "3', 7-) re.
ry
1 Monitoring rRecove ✓l�
Injection Well: ft ft /' n f Ly C� /JJ
•Aquifer Recharge DGroundwaterRemediation ft. it � � 5
!Aquifer Storage and Recovery �SalinityBanier >:19 SAND/GRAVEIRACK(itATER able) ...... „ YEtics LACE':`,�:':z,z:=:;+: .... ..
FROM TO MATERIAL EMPLACEMENT METHOD +:
`".Aquifer Test L,IStormwaterDrainage It. ft.
!.Experimental Technology D Subsidence Control ft. • ft
4:Geothermal(Closed Loop) EiTracer :20.DR1LLING LOG(attaefi addifi n'md - ; „ii S]>cefsifiieeai&ey)' =:J'�r...;`: ?;V;::::=?asfSii
. ..•Geothermal(Heating/Cooling Return) f Other(explain under#21 Remarks) FROM To DESCRIPTION feotnr.harrinesr.sont ctcry�e,er rnyiR,etal
4.Date Well(s)Completed: /02 0? / - wen ID# / 1pft./ /0 7ft. yi)a. 4 I f'
5 ,We1lLocation: lft >fft' /ll U1 :�� A�� C°�
L R 1/Ig1 1+)e ))44.,yj2e- •. ft ft. rr'�` �:•• ,
•
Facli /OwnerNa a Facility a plicable) ft ft.
ilk / fig/�11 IDll(if
2�1�7/LI 12 r I,§j5
' 11l277Af ft. ft. '
PhysicpliAddress,City.and Zip ft. ft. fo rl'Y P,,,
)�y )�/� / lilt .� .i t�il .:vx?;n?r�*t t9mr. •
e/'&//9-/Yci • t21:REMARKS,1';'.: r: ::.-1?�?3 5;.::,-'.fi::,._. ,;:}; 1''utmge �"';:..,_xi>, .::;:
County .PatcclIdentiticationNo. y-"1':�` .•m.
(PIN) ll✓Ar�/" I j �Qj.<C°�,1 >I /(' �T>/� I�j�'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: b VI C/62 41 7 PP
(ifwell field,one be/long is sufficient) 22.C rtification:
35",-AR 1,5' 3 i N 3d -��-�
I� �,, w ( Ui .,"'n e. •
a.3/..:-'57
6.Is(are)the well(s) ernanent or Temporary SignahacofCertifiedWellContractor Date
By signing this form,I hereby are that the well(s);vas(were)constructed in accordance
7.71s this a repair to an existing well: Yes or No with 15ANC4C 02C:0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair.fill out known well construction information and erpialn 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: r e 62 (ft) 24a.For All Wells: Submit this fort within 30 days of completion of well
For=WA wells list all depths tfdifferent(crumple-3@200'and/2Qa100') constuctiontothefollowing:
•
10.Static water level below top of casing: • CI (ft) Division of Water Resources,Information Processing Unit,
Ijwarer level&above caring use"i^ j 1617 Mail Service Center,Raleigh,NC276991617
11.Borehole diameter: l�O14t f/, (in) yy� 7 24b.For Infection Wells: In addition to sending the form to.the address in 24a
12.Well construction method: _ ,, ,_ .. /f{'/ above,also submit one copy of this form within 30 days of completion'of well
(• g tary rabic,direct push,eta construction to the following:
se.auger.w ) i
•
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
+�.. ,p y� 1636 Mail Service Center,Raleigh,NC27699=1636
13a.Yield(gpm) J Method of test:l ��` 1 Y�/
24c.For Water Suanly&Infection Wells: In addition to sending the form to
f� / the address(es) above, also submit one'copy of this form within 30 days of
13b.Disinfection type: ` ' Amount: 1 t Z- completion of•well construction to the county health department of the county
• where constructed.
FormGW--1 North Carolina Department ofEnvimamental Quality-Division of Water Re nieces Revised2222016