GW1--02757_Well Construction - GW1_20240506

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
//e 5,-,s/ /t//15 hit.
:14:`WATER ZONES'. : .'i;
Well Contractor Name FROM TO DESCRIPTION
• ft, ft. 1
L/5 7 -- r,,/ ft. ft. 1 '
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
r / ` FROM TO DIAMETER THICKNESS MATERIAL
/C�7 744/ 5,-/7,7, 6-0 -1---".
^ l N4 ft. ft. i. in.
Company Name 16.INNER CASING.OR TUBING.(geothermalclosed-loo
2.Well Construction Permit#: w/Q 6 (9e9 A V 7 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) p ft. �Q y/ft. �' in. (/��p /!l /) Y� v k4e.
3.Well Use(check well use): ft. ( ft in ( <
17.SCREEN .
Water Supply Well: ,,; <'. , :'r
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
I Agricultural 0Municipal/Public ivA ft. ft. I in.
I Geothennal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. i in,
I Industrial/Commercial DResidential Water Supply(shared) 18.:GROUT
t Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: J7 ,,/ ft. ft, ./�L�4 /j re�'n,‘.0Monitoring Recovery �( ft. ft. l n�r 4 f��e_
* I i
Injection Well: ft, ft. n
liAquifer Recharge [3 Groundwater Remediation S�/I tJ
19.SAND/GRAVEL PACK'(if applicable)
"'Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
*Aquifer Test QStormwaterDrainage NA. ft. ft.
®Exp-. 'mental Technology IOSubsidence Control ft. ft.
i
I3, eothermal(Closed Loop) 0 Tracer ' .20.DRILLING LOG(attach additional sheets if necessary) ' . .
' Geothermal(Heating/Cooling Return) 0Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock typo grain size eta)
0 ft, 5 ft. Sce pd 56,
/
`7 4.Date Well(s)Completed: �30 27 Well ID# , ft. 30o ft. 5i by t� ` -
5a.Well Location: rev ft. /),p ft. GR ec/,'S� e. /4
0. c , ,,,I
I �jCo ,< /Y f� s ue, ft. ) 20 ft.
ci ty/Owner Name R '� Facility ID#(if applicable) /9 0 ft, 1�v ft. ,UCrLy: SA.,4h, c,(G�
5& S ?r./�/,,, /►Gl f g„,. ,c,,,, -) v�",f76 d�.�e6ft, (5/G5 ft heArel o'rer.+n ffj4e ��'-:
Physical Address,City,and Zip ft. ft. rr -ir.
21.REMARKS ` m.•t ¢ r •v t.,. t_." .
County �� ( Parc�do�fca Identification No.(PIN) P, 6 6/I- used MAY Fi C" 2024
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient) "e)3'
22.Certification: I `"'i'.'
, Sr 545'✓i/,Bey'N -79 45
SoZ•��a. w G'r'e cs 4z
6.Is(are)the well(s) I ermanent or Temporary Signature of Certified ell 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 To with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out(mown 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: 6 I 6 .2°C'd( / /�� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: f`6/ `LY Ye 17 (ft.) 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:
10.Static water level below top of casing: -4..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: (in.) I 24b.For Injection Wells: In addition to sending the form to the address in 24a
/ above, also submit one cowl of this form within 30 days of completion of well
12.Well construction method: /3'0/d /40 kever construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also(submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 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