GW1--03459_Well Construction - GW1_20240611

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
. 1.Well C n
.A1444 tractor Information:
14.WATER"ZONES
Well Contractor New FROM TO�j DESCRIPTION
• 1/4 -y • IaS ft. ,a 6 f 2Q
ft. ftL J
NC Well Contractor Certification Number • 15:OUTER:.CASING:(for multi-cased wells)OR LINER(if AP.licable)
More an Well&Puma, INC • FROM TO DIAMETER I THICKNESS MATERIAL
I IJ
j a ft ft 61111 it ..dr-21 -- �.
(�,��'\� _: 16 INNER R BEING(georker—aL iesed_loaop)`... _
2.Well Construction Permit#: —\\ FROM TO DIAMETER THICKNESS MATERIAL i—�
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
• 3.Well Use(check well use): ft. ft. in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft ft in.
a Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
DIndustrial/Commercial Residential Water Supply(shared) IardRour . .: ... .....
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft bentonite poured
Monitoring ['Recovery ft. ft.
Injection Well: ft ft
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable) - .' '::.: . .' ,
['Aquifer Storage and Recovery Elt Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
0 Aquifer Test 13 Stormwater Drainage ft. ft.
['Experimental Technology ['Subsidence Control ft fL
0 Geothermal(Closed Loop) EnTracer .20.DRILLINGLOG(attach'additionsl sheets if necessary)
(Heating/Cooling ) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
GeothermalReturn)
O ft \o it, a, dirk
4.Date Well(s)Completed IA 1' it Well ID# L6 ft 3S ft C_ 1. 1,..�
5a.Well Location: 1111 .2 S ft• is ft bib(N�`��^% p,(/C/,L-
�(1 4$ ft
t,W S ft.
t 1_I�Y��V —
� 1� � ft ft.
F'�[t`y�/OwnerName .i �, �1���FacilityrID#(if applicable) d�
0 " .�N•, VY.Vic.G D L N L�Co -3 ft ft. — ..
Pb ical Address,City,and Zip ft. ft. t \C `r L!�, 1
11 ` \ 21 REMARKS
` � � y ol)r,1 1 1 +
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: it cirx5&t e n fa'f(.306tr4 U►f
(ifwell fief one lat/lon sufficient) D W1lits
d, 22.Certification:
35.5C - N /0• (i )4 W �� 5 136 A
6.IS(are)the well(s)MPermanent or Temporary
Si edified Well Contractor Dates
By signing this form,I hereby certj that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or Elisio 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#21 remarks section or on the back of this fonn.
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:r SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: !�� (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2Q100) construction to the following:
10.Static water level below top of casing: 3S (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: 6 1/8 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 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 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) T Method of test: air 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: granulated chlorine Amount: W D� 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