GW1--03004_Well Construction - GW1_20240520

;;Pririt'Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1,Well Contractor Information:
1 /Ilor I!!.- l v�-j'VIJ' FROM TO DESCRIPTION ..
Well Contractor Name /� / ft. ft,
J 3/ /� ft. rt.
NC Well Contractor Certification Number _i (Ito
13s,dUm�jYt;BASING"'(1'or',rntiltr?tfiedkWeil�j>.�Rrtll'NDRt. ti-ilctttlttitS:::,.
/ FROM TO DIAMETER THICKNESS MA/�TERIAL
yl S �Ci/� �� (� 6,, �n�. 1 ft. g ' ft. 1 A.6 In 4 0 1 c2-) !" vc, , .
Company Nefne ,, ( 1ti U NER:. AsI1�GtC1It�. . liie�(tit ofli6Ytdti)±$lo3edlt`U11p7 `/':zr
5 1 �'� — ) �- / 5 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ��✓VVV !/ c ft, ft, In.
List all applicable well construction permits(i.e.UIC.County,Slate,Variance,etc.) — In —
ft. ft.
3,Well Use(check well use): -;f7 SCcItE N. i .a;-.st• '.; _�:.�`� -x:i `t2 rr '`.; ! ti ,,
WAgriculturalater Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Q p
Munici al/Public ft. ft. In,
Geothermal(Heating/Cooling Supply) `:,,Residential Water Supply(single) ft ft In
Residential Water Supply(shared) T 19i;61Z t1!t` m r 1
Industrial/Commercial v;^:?"''�a"•`'`: ..,,�: :.`.. r
FROM TO MATERIAL EMPLACEMENT METHOD•&AMOUNT
,,Irrigation (i ,t• 1�O ft. bQ,1a .}tii�E re,(4_rPal- 12 Cja_.1 ,
Non-Water Supply Well: �JJ
Monitoring DRecovcry ft. ft. _
injection Well rt. ft,
Aquifer Recharge Groundwater Remediatlon
i9}SANP/ P.A,VEL:PAO)Ci(( • z. ,.
(iR tL (11�) ;
Aquifer Storage and Recovery OSalinity Barrier FROM TO MA"'EIUAL EMPLACEMENT METHOD
ft, ft.
Aquifer Test , DStormwater Drainage
-
Experimental Technology tip;; DSubsidence Control ft. ft
Geothermal(Closed Loop) OTracer :T¢ailtI,UiN01;,0:4t%(tited0'.ptint.tlorialiehea'teJf;PBe fsairy)
FROM TO DESCRIPTION(color,hardest',toll/rock type,grain size,etc.)
Geothermal(Heating/Cooling�Return) Other(explain under#21 Remarks) 69 ft, '/I ft J I �t/G�
4.Date Well(s)Completed: x'// -'?Q '21"L7 v�'ell ID# / U. )`15' H. , 1 LYL1��
ft. rt. ,_J
5a.Well Location: _}_
I)/A d i-A. PA/nl�r-
ft. L 1) [ Z4
Facility/Owner Name Faollity 1Dp(if applicable)
!/II a ft.�. _d-c--;r j. f<,ft, ft.Physical Address,City,and Zip
Kl�t e Y fo re,' i31,1tFiMAK& ?y2,, _
r_s
County Parcel Identification No.(PiN)
5b,Latitude and longitude In degrees/minutes/seconds or decimal degrees! 22.Certification:(if well field,one 1st/long Is sufficient)
__13. ,. 5q 6 -co N - ,11, 74 o 5',y w avvS)? Ca i f
Signature ofCartitled Well Contract
6.Is(are)the well(s) Permanent Or Temporary '
By signing tit!:form,!hereby cerlyy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or rEiNo with 134 NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repalr,f/l out known well copstructlon!,(format/on and expiate the nature of the copy of this record has been provlaed to the well owner.
repair under 411 r¢na,krsectlon or on the back oj this form. 23.Site diagram or additional well details:
You may use the back of this pegs to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction details, You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells drilled: SUBMITTAL INSTRUCTI<�$9.Total well depth below land surface: I"/�
r (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(fdifferent(example-3Q200'and 2Q/00') construction to the following:
10.Static water level below top of casing: d (ft.) Division of Water Resources,Information Processing Unit,
g
{(water level is above casing,use//"+ Raleigh,NC 27699-1617
" 1617 Mall Service Center,
11.Borehole diameter: (7/'-f (in.) 24b.For Injection Wells: La 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: 1,(O I `L Y y construction to the following:
(i.e,auger,rotary,cable,direct push,etc.) / Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY; 1636 Mall Service Center,Raleigh,NC 27699.1636
•
(j Method of test: /^i r 24c.For Water Sunni), &inigction Wells: In addition to sending the form to
13a.Yield(gpm) I l the address(es) above, also submit one copy of this form within 30 days of
type: L )iY I it F Amount: I C Le(O completion of well construction to the county health department of the county
13b,Disinfection / where constructed.
.. - ._ro_..i.,..,..,...,or n..at(ev•Division of Water Resources
Revised 2.22.2016