GW1--03059_Well Construction - GW1_20240422

WELL CONSTRUCTION RECORD (GW-1)
For Internal Use Only:
1.Well Contractor Information:
A(C5 4., 6)'ss�pet J
14.WATER ZONES -
Well Contractor Name FROM TO
DESCRIPTION .
'-1 75 3 --/ ft. ft.
NC Well Contractor Certification Number ft ft.
7; / j 15.OUTER CASING for multi-cased wells OR LINER if a.,licable
T I SC/`/`r��� Gv FROM TO DIAMETER THICKNESS
y ft. ft MATERIAL
Company Name , ; in.
16.2.Well Construction Permit#: �� ('(� FROMNER CASING OR TUBING(geothermal closed-loop)) '
List all applicable sell construction permits(i.e.UIC,County,State.Variance,etc.) ft. TO ft DIAMETER in. THICKNESS MATERIAL
3.Well Use(check well use): ft ft. in.
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Water Supply Well:
.17.SCREEN.,'
a Agricultural FROM TO
°—MunicipaUPublic DIAMETER SLOT SIZE THICKNESS MATERIAL- _
Geothermal(Heating/Cooling Supply) °Residential Water Supply(single)
111 �/ tt. ft. in.
Industrial/Commercial (°Res ft. ft. in.
idential Water-Supply(shared)
Irrigation 18.GROUT.- - -
Non-Water Supply Well: FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
�iMonitoring ),0 y ft. D ft. 14 to'a+4/ %r ./ �e. .n.' /e' t_
Recovery 7 ft. it. p
Injection Well: �^^ia/1C-4-� //l5 S.i�� „ „.1—
*Aquifer Recharge °GroundwaterRemediation ft. • ft' f4�td
NiAquifer Storage and Recovery L°Salinity Barrier 19:SAND/GRAVEL PACK(If applicable) _
FROM TO MATERIAL
1Aquifer Test °Stormwater Drainage ft. • . ft. EMPLACEMENT METHOD
II E •erimental Technology °Subsidence Control
ft. ft.
Geothermal(Closed Loop) °Tracer '.
10.DRILLING LOG(attach'additionafsheets if necessary)::
Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sail/rock
rnI n 9 O ft. _ type,grain size,etc.)
4.Date Wells)Completed: o� ` d 7 Well ID# ft. 5 f t. S5�J . r e" 50,./
S 30 ft.
5a.Well Location: l�� �(`��
O ft. `(G ft.
/4:5 h Scats/ //D ft. ft_
_ Facility/Owner Namc ��d I Q� S�iof1r ti�/
Facility ID#(if applicable) /g U ft. ft
5 .AGO ,� �l�k� 6:u:�.� �/�7
S`OS �h._l f��, /� t-/—a�rl . a�37‘ �cv ft. 3o� ft. �2 /
Physical Address,City,and Zip J J���� 5 ti� i
ft. ft.
I1 L � ..
/7 o 4 e, 6.0 Jn/ 21:REMARKS., I t .11..7.i ors $T., l ..
County Parcel Identification No.(PIN) APR 2 G ZU C4 '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:(if well field,one lat/long is sufficient) _.�:- SF:;;-.a 'Jr .
1 c/ Q °�r e 22.Certification; li�" • c. •�,
6 J t7 I n j��,` >,�. av •
73gN 79 13 5J 0 W
)1 � � 3 — V—�?
6.Is(are)the well(s Permanent or Temporary Signatu o Ce i ed ell Contractor
Date
7.Is this a repair to an existing well: Oyes or triallo By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
If this is a repair,fill out known well construction information and explain the nature of the copy ofthis record hasbeen provided to the well owner.
0 0 Well Construction Standards and that a
repair under#21 remarks section or on the hack 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
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construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additionaLpages-if-necess
drilled: 6 0 ir..f ACC,,,,,I h/L.(/ _
/+ De/
SUBMITTAL INSTRUCTIONS
- --9.—Totaiw „elI depth below land surface: a (fit- 3t
For multiple wells list all depths([different(example-3@200'and 2Q100) at') 24a. For All Wells: Submit this form within 30 days of completion of will
construction to the following:
10.Static water level below top of casing: /��
If water level is above casing,use"+'If Division of Water Resources,Information Processing Unit,
5 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.)
�+ 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Jan// AO
above,above, also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) J construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
1636Mail Service Center,.Raleigh,NC 27699-1636
13a.Yield(gpm)type: Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
13b.Disinfection the address(es) above, also submit one copy of this form within 30 days of
Amount: completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-27.ant F