GW1--02796_Well Construction - GW1_20240506

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
1.Well Contractor ormation: 1
.1frerPfa, fie,tt- G/- 14.WATER ZONES- !
FROM O DESCRIPTION
WeUC ctorName
t � - Tait / , ���
[v�� -A a ft. ft. 1
NC ell Contractor CertificationNumber z ed 15.:OUTER CASING(forinulli-cased',Wellsj_ORLINEI€(if ap llcabie) ..
� L F ROM TO DIAMETER TtflTC�,I7INrE�SS MA,,//TnnERIAL
Co n Name ft G 05"ft" C r m• 51..t�-or_1 ?ie
Y Ll "_16�INNER CASING.OR:TUBING(geothermal elosed-looj►)
2.Well Construction Permit#: / G FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.111C,Count};State,Variance,etc)
ft. ft. I In
H, ft. in.
3.Well Use(check well use): 1
17.SCREEN '
Water Supply Well:
6 FROM TO DIAMETER SLOT SI THICKNESS MATERIAL
Agricultural M blic SIZE THICKNESS
ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) g, U, iln,
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT t : -:.
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: R' ft.
Monitoring QRecovery ft. ft.
Injection Well: _ ft, ft
Aquifer Recharge OGroundwaterRemediation 19:SAND/GRAVEL PACK(if applicable) :'
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage © ft. ft. i.. 4 Ci 9 Audi G1.../
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer
20.DRILLING LOG(attach additional sheets If necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) © qo ft 47 G/ C e/�' f1
4.Date Well(s)Completed o^d Well ID# ic' ft' /oj ft. /, etz-'-t.°f f--L
5a.Well Location: / ,5'ft- d yam fin'/' e -
- - J ft. ft.
FacilityID#(if applicable) ft. ft. - \,;�..1, a=PT—,. 1 x �l 1
Facility//OwnerNamc // /� It A A i ,
` �ll/ �r/� /✓/�n��`// ft. ft.
ft ft. • MAy 0 6 2024
Physical Address,City,and Zip
21.REMARKS lr.`<-)-.,. .`-:-1 `�-
County Parcel Identification No.(PIN) ,,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 'n
(if well field,field,one lattnonngg7iss sufficient)+u �/ yy G/� 22.Certification:(win. 1,(-1 � y�
.3 < , ( / ( N ?7 c Y V w
421_4e.oc. ^�.t/l afc��aY
Tern o Signa oft crtiified Well Contractor
6.Is(are)the well(s) Permanent or p rary
By signing this form,1 hereby certifythat the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: lJYes or o 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#11 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
You may also attach additional pages if necessary.
construction details.
• construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells i.
drilled: /y SUBMITTAL INSTRUCTIONS'
' 9.Total well depth below land surface: t• �S (ft-) 24a.For AU Wells: Submit(this form within 30 days of completion of well
For multiple wells list all depths iif different(example-3@200'and 2@100) construction to the following
10.Static water level below top of casing: Cp D (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use
use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: l!a' (hi.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
t„ �� /� above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: �5 r ( / construction to the following: ,,
(i.e.auger,rotary,cable,direct push, c.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: Q 1636 Mall Service
/ Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 0 Method of test•.``i \+\-kVI 24c.For Water Supply&Injection Wells: In addition to sending the form to
I� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: i Amount: 3 C-4: completion of well construction'to the county health department of the county
where constructed.
.. -—" , North Camlina Denartment of Environmental Quality-Division of Water Resources Revised 2-22-2016