GW1--01878_Well Construction - GW1_20240322

ON
STRU('TION RECORD GW-1 I For Internal Use Only t. 5 �Well Contractor information; ��� �Sw
Id J Q
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Well Cont ame ` GL '!L / 11 W R 7A ATE \L5.
r F OM TO DESCRIPTION
// - - 6.:N R. E)0 R. /^ 19La .
9 ft
NC Well vnonetot Certif cnGan Number Tet5 ft-atUTER CASING fir mdd'eiseg ar v�f
( , TAb)OR LINER(If apeneabis). •
�/ ��` PROM I f DWN ITER THICKNESS ' MATERIAL'.
- -'r �/ \!rC R. It TO R. Is.
Company Nana
^n[� /� IC INNER CASWG.ORTIIIING.(EaotistraenTtlasad400p) �i
2.\Veil Construction Permit 0. 1) 'i(f} I) FROM_ TO DIA.M E1 FR I THICIENLVI MATER IA I.
Lau all applicable well conurrrnon permit.t7 e br .Cornry,Stare.r aricree.etc.) lee) ft. `?' ft. 6 -la S) ,t _ (� `/�
3.Well Use(check well use): R. 7 rt. in. `�- Y L/
Water Supply Well: 17.SCREEN
Agricultural �M icipallR bllc FROM ft. TO R uIAMe est SLOTstZ -mamas 1 MATERIAL
Geothermal(Heating/CoolingSu esidential Water Supply O ---
Supply) PP Y(single) R. R In.
industnai'Commercial OResidentia114'ater Supply(shared) -
1a.GROUT
irrigation IROM TO MATERIAL 1MPIACeM eT MIn1Oo A AMOUNT
Non•WaterSupply Well: V/'c fft. i1 3 R. ( �, 'r7 (j/� 4 ii 4 / y golf)
Monitoring flttrrovci) rt.
b R.fO� ._
Injection Well: J' �lfj '5
ft R.
Aquifer Recharge ❑Groundwater Reinediatton
19.SANDY:RAVILPACX(if appItiabte)
Aquifer Storage and Recovery ID Salinity Barrier FROM TO MATERIAL GNP LA CUM ENT Mm10D
Aquifer Test 0Stormwater Drainage R.-~� ft•
F.xperimenial Technology D Subsidence Control H. R.
Geothermal(Closed i.rxip) D Tracer 20.DRILUNG LOG:Winch additional itieain'ti.iiiitirj)
FROM TO Dt5CID PITON e.lr\velar ...Newt , rain do etc.
Geothermal(Heating/Cooling Return) ❑Other(explain under 621 Remarks)
() R. 5.- R. t't /c./1 %jCl bt-A) f
4.Date Well(s)Completed:,_-aly Well Ma ! - rt /1 2 R- /rR°IrP /)E,J -/i 1114-i ' --
Sa.Well 1.00ccati/on:/y _�✓ l h ''/ -/J 21-21
Facility/Owner Name / Facility IDa(ifappiicabk)
s-tati (.41ik hi-"ff�- T44;L
Physical Address,City,and Zipft -- . '
Ai/li 4� / oc:0/ /l)74 i 21.REMARKS
County Pared Identification No.(PIN) -^ r- ^I
j I r-
Sb.Latitude and longitude in degreesiminutesiseconds or decimal degrees: '" --- 4„
(dwell betel,one 1a:Aang is sufficient) 22.Certification: /p p „ f� A
,�� // c /00 N s/655 j i ? 244// W * ' MAR G �U2.y
6.Is(are)the well(s) ermanent or DTemporary 8ti"are o Bed Welt Contractor ^•^ :. - ,
By signing this/orm,I hereby certify that the'rill(s)war firers)eavwcikd in accordance
7.Is this a repair to an existing well: Dl'es or with l5.l NCAC 02C.0100 or 1JR,VCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill oaf known well construction information and erputn the natter of the COP/of q,r record has bee,,provided to the will owner.
repair under al/remark sectton or on the back of this form
23.Site diagram or additional licit 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 al:to mach additional pages if necessary.
drilled: SUBMITTAL INSTRUcrIUV
9.Total well depth below land surface: 5- (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list oil depths if different(example.J 00' l@l007 construction to the following
10.Static water level below top of casing: 7 120 (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: 6 (in.) 24b.For iniection 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: c g /Q)( construction to the following:
(i.e.auger,rotary,cable,direct push e
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpin) iV _Method of tesr. !/1/i 24c. For Water Suooly & Inisllon Wells: In addition to sending the
/ the address(es) above, also submit one copy of this form Within 30 days of '
13b Disinfection type:0j�[�it// Amount_ � � completion of well construction to the county health departtpen; of the county .
where constructed.
Form G W'-I North Carolina Department of Environmental Quality-Division of Water Resources Revised jjj6
MN