GW1--04475_Well Construction - GW1_20240730

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WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
1.Well Contractor Information: /
.'(Y 'r ,�(:of t ell, 14,WATER ZONES
fiWWell/l,,��ntracttoor Name FROM FROM TO DESCRIPTION
oR C.Y a - H ?� i O R. S' c,i,.)
ft. ft.
NC Well Contractor Certification Number
Welt
1/�J /� �f ^- `p / / 15.OUTER CASING(for mnitltased wells)OR LINER
�(if i)
.'(5 WC1 L t1G/2l: I'UI!`P Ut-Cf l� FROM TO DIAMETER THICKNESS MATERIAL
{L 7 f R. lc S- to. 5 DR1 0l.I ?ire_
Co.�.:� Name / f�
/ 3 ' 1 / 16.INNER CASING OR TUBING(geothermal closed-loon)
2.Well Construction Permit#: 7 ! FROM TO DIAMETER THICKNESS MATERIAL
List all applicable Hell construction permits(i.e.UIC,County,State,Variance,etc) It. ft• in.
3.Well Use(check well use): ft• ft• in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
()Agricultural O icipal/Public ft• ft in.
in Geothermal(Heating/Cooling Supply) el Residential Water Supply(single) fL ft. in.
0Industrial/Commercial ()Residential Water Supply(shared) 18.GROUT
rl Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. tl. h1f�,.,�
7 tine_ --- xx-E.0 14,-)
aMonitoring ()Recovery ft. It.
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation 19.SAPID/GRAVEL PACK N applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. R.
Experimental Technology 0 Subsidence Control ft. ft.
jGeothennal(Closed Loop) ()Tracer 20.DRILLING LOG(attach additional sheets if necessary)
DGeothermal(Heating/Cooling Return) [Other(explain under#21 Remarks) FROM TO DESCRIPTION(eider,hardness,sail/re&type,grain dee,etc.)
4.Date Well(s)Completed:0'7./7 y Well ID# Gel ft.
? ft, 6 4-e- e Yf�
5a.Well Location: --)7 fr. i ft' ero i y•/1-7L2'
,4,7,f /9/C/f1A-e e a s 7a F y . ft. ft.
FacilityiOwner Name Facility ID#(if applicable) R. ft. .- .. ' , `:.
5)G . 4/-et'i s //, �i %o.�j,� ifri ��'f r,_ ft. ft. -... •1 i 1
Physical Address,City,and Zip 1 f r--.1 q ft ft J U L 3 0 2024
21.REMARKS
� 3�r t 0iy29t? In`:.:::t...i. r,-L,h -,;Imp
County Parcel Identification No.(PIN) D'f:'CJ 3•:..3
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: /6
(if well field,one 1at/long is sufficient) 22.Certification: vnr� ( a - tq ,,/ '
3s � / ! 10 N d /° 8 .? g/V W � ,�. r. (dG/ 7,4( (J O7-/7i1�
6.Is(are)the well(s) Permanent or ()Temporary f ""Cecn tfTed Well Contractor Date
By signing this form,1 hereby certify that the welts)Hat(were)constructed in accordance
7.Is this a repair to an existing well: ()Yea orVo with I 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: (l 0✓ (t ) 24a. For AU Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths!I-different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 3(2 (ft.) Division of Water Resources,
If water level is above casing,use"+" Information Processing Unit,
' 1617 Mail Service Center,Raleigh,NC 27699-1617
1
11.Borehole diameter: "b (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
1 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: C1.,-NA--1
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: ;c)Q (.r J,e_ 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 Amount: Y C(/ 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