GW1--04350_Well Construction - GW1_20240722

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.'WATER`ZONES = t
Well Contractor Name l FROM TO DESCRIPTION
J� a R. ft.
`7 6_7 6 ft. ft.
NC4cII Contractor Certification Num 15.'OU`�ER'CA8ING for multi .cased we sOR'VNEIC if a llcable FROM TO DIAMETER
�I THICKNESS MATERIA
Company N e ft. 4 (L 6 r 7_n. I'D R Z 1
r I ), .( 'j h >•Pi.1NNER;CA$INGiORTUBINO] e`fhermal_elosediloo' .•;-%
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits 0.e.UIC,County,State,Variance,etc.) ft, ft. 1n•
3.Well Use(check well use):
Water Supply 19°SGREDN
PP Y Well: FROM TO DIAMETER SLOT SIZE THICKNESS ' MATERIAL
Agricultural QMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ft• ft. n.
Industrial/Commercial 131tesidential Water Supply(shared) 18i,GROUT
.—)Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. e • .I2% Y - h A 5
Monitoring 13 Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge []Groundwater Remediation
-19SAND/(;RAVE PAG 1ka Ilcable '
Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) OTracer =20 DRILLING 'OG'etfectraddltional•aheete lf:netessa
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks) I
FROM TO DESCRIPTION color,hardaeu sollfro-c/kk type rain sl etc.
A ft. ft. l ✓ j L-IL
4.Date Well(s)Completed: Well ID# (J ft' t' t"1 to
5a.Well Location: /� / ft. ft. r
GhY i5 /'J t arts / G/�yfo e)r1vl<er
Facility/Owner Name�g n� n Facility ID#(ifapplicable) ft. ft.
/ rl 4 ft. n.
rt. rt.
Physical Address,City,and Zip s
C,ta I)YJ l�� 21 REMARKS:: '
County Parcel Identification No.(PIN)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
6.Is(are)the well(s)SPermanent or OTemporary Signature ofJORied Well Contra r Date
By signing this form,I hereby certify that the rvell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or NNo with JSA NCAC 02C.0100 a•1 SA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,Jlil out known well construction igformation 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 thisfor-m. 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 I GW-I 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: A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2@1001 construction to the following:
10.Static water level below top of casing: v (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" / 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: L (in.) 24b.For Iniection 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: O 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
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13a.Yield(gpm) Method of test: / 24c.For Water Supply& Injection Wells: In addition to sending the form to
J the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: L)Z>'D Y/ Amount: C� s completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Waler Resources Revised 2-22-2016