GW1--04583_Well Construction - GW1_20240731

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WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
1.Well Contractor Information:
. tntr jecti %>hf(ee-1G 14.WATER ZONES
well tractor Name FROM TO DESCRIPTION
dl4 <D, - A 3 yart. 3c ft• So 6,i1
NC Well Contractor Certification Number
(� 15.OUTER CASING(for maitltned wells)IO'R LINER(1t )
rS t ieJI ai1Ci 1 p&it�CJ LC FROM TO DIAMETER R /6 rt. `�' in.
s DP is Zia 1 1�YC
THICKNESS MATERIAL
Co Name Y
�,,� /,�/(-ad
,/ (� \J L 16.INNER CASING OR TUBING(geothermal elosed-loop)
2.Well Construction Permit#: 4 f' d. -`� V� / v t FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG County State.Variance.etc.) ft• ft. in.
3.Well Use(check well use): ft, ft• hs
I Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SiZE THICKNESS MATERIAL
0Agricultural QMunicipal/Public ft, ft• in.
Geothermal(Heating/Cooling Supply) tsidential Water Supply(single) fz ft. in.
Industrial/Commercial OResidential Water Supply(shared) 1&GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft (/ rt' bin �i r)� � 1
Monitoring Recovery rt. rt.
Injection Well: ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Battler FROM TO MATERIAL EMPI ACEIKENr METHOD
Aquifer Test �Stomrwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets If necessary)
FROM TO DESCRIPTION(eoNq Yardmen,wlYndc type,gala da ern)
Geothermal(Heating/Cooling Return) �Othe�plain under#21 Remarks) yo n d C l�y
4.Date Well(s)Completed:7-2 y Well ID# /L�, ft• /`s ft. /�6..t---e?`"-`ei
5a.Well Location: stirs ft• 365 ft. ��,.�.1 y')`"L
ACada P GG'/i-e ft. ft. .---{
9utility/Owner Name Facility 1D#(if applicable) ft. ft. '`- ^ i l S`:= '
/- a'd•C,,1 C y' >7` / ft. ft. _ .
Physical Address,City,and Zip
ft. rt. 3 , ZG�
/ p 21.REMARKS '- t '�`
C. rr/'iCO, I.a (q 6 '
County Parcel identification No.(PIN) 1r r. �.! � .�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r�
(if well field,one 1st/long is sufficient) 22.Certification: Q. a ' tq
6.Is(are)the well(s)0Permanent or Temporary L4.v
Cr ertrRed Well Contractor Date
By signing this form,i hereby certi'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yea or o with iSA NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out!mown well construction information and explain the nature of the ropy of this record has been provided to the well owner.
repair under#11 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if nececcary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: .3 65 (it.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd different(example-3®200'an(d�2Q100') construction to the following:
10.Static water level below top of casing: -/ 0 (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: Gur'ir (h>_) 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: C].,u1 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: L' ', 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) SO Method of test: �.Q-�,?�cr (7E 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 I Amount: 3 (I) 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