GW1--03338_Well Construction - GW1_20240603

1 1111\1 VIM
WELL CONSTRUCTION RECORD (G W-1) For Internal Use Only:
1.N....y.0Si ontractor Information: 1 ,-
Jam CSC(\ Gi t O S C \ 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
W
90 3- A 0 ft. . G G G ft" {4a tI ON.0
n. n.
NC/Well Contractor Certification Number 15.OUTER CASING(for multi-cased weBs)OR LINER(if ap Rea tie)
" 1 ,)D /e n V 1( ) I r r • FROM TO DIAMETER THICKNESS1 MATERIAL
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 177
0,13'On 3 I"4- FROM TO DIAMETER/ THICKNESS MATERIAL
1 ,
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) O it ft. tp•2Y In. G oyez% f y e
3.Well Use(check well use): ft' rt. in J
17.SCREEN
Water Supply Well:
Agricultural 0M FROM TO
ft. ft. DIAMETER SLOT SIZE THICKNESS MATERIAL
cipalfPublicin.
3 Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
Irrigation FROM TOC. MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 2ft. �t4an•'E. QO,A.
Monitoring Recovery _ ft. ft. �`�,�
Injection Well:
ft. rt.
Aquifer Recharge QGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery EiSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage n. ft.
DExperimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) [Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.)
0 ft. 2Z ft. C \U`Y OVCi:Cptxrcwt.\
4.Date Well(s)Completed: 5-21-.1 4 Well no 22 ft. 1 )0 ft. G1 ran t _
5a.Well Location: n. ft.
RR Rter; c� ft. .. -
Facility/Owner Name Facility ID#(if applicable) ft. ft. ,� �
ft. ft. : LU(.+
5F' Kell elols 111txptrNa(et1NC ,28-1a1
Phc,ical Address,City,and Zip J ft. ft.
e umCOmbe rrTzr o1002} 21.REMARKS
County ntc Parcel Identification No.(PIN)
(if ell Latitudee and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C on:
c.1-9462171' ° N g . L0z1 /GS ' w � e- `E-='-- J. s-.2,- 2y
6.Is(are)the well(s) 'crmanent or Temporary Signature of Certified Well 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 QYes or o with 1 SA 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: -110 (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 r@200'and 2@100) construction to the following:
10.Static water level below top of casing: (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. (D • 2 C (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: C3 �( construction to the following:
(ie.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY
I WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) J•-- Method of test:"l• Call • Je- 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
13h.Disinfection type:OM rsr i n Amount:1 49.4,S __ 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