GW1--01980_Well Construction - GW1_20240401

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
J am i S a \ t �� 14:WATER ZONES ,.. 5, ..
Well Contractor Name FROM TO DESCRIPTION
-4o C r PA 0 `t. /p 111,1 ''ikon
ft. ft.
NC Well Contractor Certification Number -15.-OUTER CASING for multi-cooed•Ivens OR LINER if n livable) -
4'"tom,CA lam!\1 Ga\ /l/e I 1 J I 'I\ ``�J ,nC. FROM ft. TO
ft. DIAMETER THICKNESS hL1TERIAI
in.
Company Name /n� ('� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: wf• d o - i o Zl FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) 0 ft• la1 f. G.Sr in. 1211 ,()V��s
3.Well Use(check well use): ft. ft. 1n [�
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
*Agricultural OM •' ipal/Public ft. ft. lin.
*Geothermal(Heating/Cooling Supply) I esidential Water Supply(single) g. ft. ;in. " •
NI Industrial/Commercial [Residential Water Supply(shared) 18.GROUT
' !Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: a ft• -20 ft. diQ#-ip(y%.r Q -'J --
NIiMonitoring Recovery , _ ft.- ft. CL`c
Injection Well: - -
ft. ft.
&Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Ili Aquifer Storage and Recovery ()Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
i Aquifer Test DStormwater Drainage ft. ft.
II Experimental Technology EtSubsidence Control ft. ft. I
"Geothermal(Closed Loop) DTracer 20.DRILLING,LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
NI Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks)
o ft. IS2 uie
ft. C.lal (a .0tte-C
4.Date Well(s)Completed:3- )1" 2 9 Well ID# 12 2- ft. pie, ft. �'nrt x..e
5a.Well Location:ee i..m:4- Soli 7(,ts{•'t'. `Tl t.s r . ft• ft.
tve,0 ft. ft. -
Facility/Owner Name J Facility ID#(if applicable)
/ ft. ft. }'" -�'K i nl t a
17- latanep I-44r.Rd , ROstacht NAG old I1Z. ft. ft. APR 1
2024 ,
Physical Address,City,and Zip ' ft. ft.
l�aY�SA/(vQY�i'G 75�I -8 -a 7?1,-o0 21.REMARKS i, -' ....•^1 '�Dwc?:.-,.s.,.
County Parcel Identification No.(PIN) •
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -- - - -
(if well field,one lat/long is sufficient) 22.Certification:
35 . ' SI . 439 3 N C b 4l 'g'. 083 V�II w �__--.' 1 3 - laj'2�
6.Is(are)the well(s) -Permanent or Temporary Si ature of Certified We Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or No-- -- - - with 15A NCAC 02C.0100 or 15A 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 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: I) .1 ft.
P ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following: I •
10.Static water level below topof casing: 1
�O O (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: (e, 2 (in.) 24b.For Injection 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: \t 1�-t?.1?A construction to the following: i '
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) O. k Method of test:Tk.1. cb.'Q/t-24c.For Water Supply&Injection Wells: In addition to sending the form to
�l the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chk or-e- Amount: 11= �c� 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