GW1--04746_Well Construction - GW1_20240812

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Co Info t :
14.WATER ZONES
Well Contractor Name FROMft I TOft. I DESCF1Yfiglg
(544),...V
Apo ft 1/40,0
jo ft F f
NC Well C/Jertification Number 4$P.-•; 15.OUTER CASING(far ran ti cased wells)OR LINER(If hie)
/ ��� FROM TO DIAMITI:R THICKNESS MATERIAL
Company Name
ft
fy�` ft
�_ in �L,lf (s0 �,
`' ' t ,.- a/L�"T�t 16.INNER CASINGv OR TUBING��otherwat dosed-loop♦)
2 Well Construction Permit#: w Q �v)`� FROM TO DIAISn TI:R THICKNESS MATERIAL
List all applicable well construction permits(i.e.UDC',County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Su Well: _
ppl FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ©MunicipaVPublic Soft //Oft a in. la Sc4 yo .✓e'
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ✓ ft in A
Industrial/Commercial OResidential Water Supply(shared) IS.GROUT
Irrigation FROM TO ;A:FAL EMPLACEMENT METHOD&.%MOS NT
Non-Water Supp Well: O ft 4•2 O ftr`� ��
Monitoring 0Recovery ft. ft Ctf`i11�t j�
Injection Well: - J J r
ft. ft.
Aquifer Recharge r •.wttwater Remediation 4f applicable)It SAND/GRAVEL PACK
Aquifer Storage and Recov •• I Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage e, ft //d ft. �� � / "tvl,
Experimental Tee . :: 0Subsidence Control ft ft
Geothermal(Closed Loop) i Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return Other(explain under#21 Remarks) FROM TO DescluPlron(color,tyrdness sotYroct type,rants size,etc.)
Oft ft 74 ,,
4.Date Wells)Completed:‘.41i Wed ID# ft al y �
ft O)
5a.Well Location:
s'ft y0 ft 4s1,5
Facility/(honer Name to Facility ID# if applicable) g7 DR. !/O ft sz,'�'�J'"
I 0 tk- AvkAil ` O��1�(�(y / ft ft Plays' I Addresm.City,,and Zip V�- IJ (J(, ] •
ft. ft
tfJPIU
tfq 06%71 # .
°i 11 P
, . .
21.REMA.17,,
4. 6,,,,,,,,,_ ,. .,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one lat'long is sufficient) 22.Certifies
N W `f— ir-/47
6.is(are)the well(s)frmanent or E3Temporan Signal of'Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constnicted in accoraiarce
7.Is this a repair to an existing well: DYes or with 1SA NCAC 02C.0100 or ISA NCA('02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the native of the copy of this record has been provided to the well owner.
repair wider 021 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 INSTRUCTION4
9.Total well depth below land surface: //Q (ft.) 24a. For Al) Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: I (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,me"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: ( (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: 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) Method of test: 71141 24c.For Water Supply &IniesHun 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: j 0 L 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 Water Resources Revised 2-22-2016