GW1--01516_Well Construction - GW1_20240312

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
�P..QIAh . 61y6t 14.WATER ZONES
Well Cont ctorNarlie j FROM TOOL DESCRIPTION
C7S� � [ �0 rA00 fIL : / 4 �]�1�1�
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap livable)
rr II-- ' q FROM TO DIAMETER THICKNESS JMERIAL
Nf VI�r Ec�V 1Q 1��Y t I lc� \V1 C. (•i rt i rt (c,'J`� i� .rt:7-LC l i
Company Na (� 7t} / fc t�� "� '6 q)aj, "d---2(
C 16. w R CASING OR TUBING(geothermal closed-hop) _
2.Well Construction Permit#: c39. I \I q FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.WC,County.State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. it. in.
Water Supply Well: 17.SCREEN /(114
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
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❑Geothermal(Heating/Cooling Supply) IAResidential Water Supply(single). ft• ft. in.
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17Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑irrigation ❑Wells>100,000 GPD FROM TO MATERL L, EMITFMENT OD&AMOUNT
Non-Water Supply Well: (-0 ft. ft. �)a^Y 1�(�"-1 (NV�e
❑Monitoring ❑Recovery ft- 3 ft. , ,fix,,
Injection Well: `� a� 'l Pe�
ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(if applicable) /v 4
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL - EMPLACEMENT METHOD
DAquifer Test ❑StormwatcrDrainage ft. ft,
❑Experimental Technology ❑Subsidence Control ft. IL
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/pek-pq grain size,etc.)
(0 H. S 0 f F JiZ ' ��6
4.Date Well(s)Completed: A ai�l1 C a well ID# 9 9!18 � IL 15-ft. c J�JC,. d,
5a.Well Location: `76---0• ,?a., e ./,2l .C__
Facility/Owner Name - FacilitylD#(ifapplicable) R• H ,ram• :wI 4 ,
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AO 1 O ft. ft.
Physical Address,City,and Zip I.p t� �t` IL R
69-t'a..l',,1\'e_ • 1 0 1 Lk 'OVA CJ C3 21.REMARKS ��
rihc:wr+ ;: �+_
County Parcel Identification No.(PIN) l•S'�`i013 y r'OG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient)
22. c lion
:)(e_, b t-k-o 01 N 1 CIC- 3b 12 r w
` 3v+ -Iii
6.is(are)the well(s): ,Permanent or OTemporary tgnaturc of .ertified W ll ontmctor Date
` 1ty signing this form,whereby certify that the well(s)was(Were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I .ko 15,1 NC AC 02C.0100 or 15,1 NC IC 02C.020(1 Well Construction Standards and that a copy
If this is a repair,fill out knovm well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 renar•ks section or on the back of this form.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I GW-I is needed. indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: t. 24.SUBMITTAL INSTRUCTIONS •
9.Total well depth below land surface: a A (ft.)
For multiple wells list all depths if djfJ rent(example-3@200'200'and 2 r@/00') Submit this G1 V-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: o (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing use"+"
IL Borehole diameter: (
-- 24b.For injection Wells: Copy to DWR,Underground Injection Control(TUC)
P - (in•) �,1t n Program,1636 MSC,_Raleigh,NC 27699-1636
12.Well construction method: 19-1Q -Q-fl 1 -i( 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.o.auger,rotary,cable,direct push,etc.)_ _ • - - - - - -- county environmental health department of the county where installed
-i- - - -
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) ` Permit Program, 1611 MSC,Raleigh,NC 27699-161 1
1 0 Method of test: �I 8/
nI � U
13b.Disinfection type pr OC Qtk WI fe- Amount: 8 OZ.. .
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Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2013
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