GW1--04877_Well Construction - GW1_20240828

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Informatio : I
C J 0[Y, p y( ��d, Cif-
14.WATER ZONES
Well Contractor 14ame FROM TO DESCRIPTION
- ft. ft.
#614 4 ft. ft.
NC WP Contractor Certification Number ,/A1 �J 15.OUTER CASING(for maltl cased wells)OR LINER(If ap livable)
C l � // //u / 'Dr ��C-r FROM ft. TO ft. DIAMETER tn. THICKNESS MATERIAL
Company Na e ( r /� !\� ( 3 6' ) �S 5 n-R d.l P VG
P Y ) �J /� yA 16.•INNER CASING OR TUBING(geotheintal closed-loop)
2.Well Construction Permit#: 5"� vC 30/ 4 651.t/ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,C arty,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. In.
OGeothermal(Heating/Cooling Supply) 118Residential Water Supply(single) ft, ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: V ft. ,..10 R. j)emit/lite p0 f f J hLLgj3
❑Monitoring ❑Recovery ft. ft. I �J
Injection Well: ft. rt.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL.PACK(if applicable)
DAquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING'LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION()Dior,hardness,soil/rock type,grain size,etc.)
ft. q rt. Z C)a jl
'/ 1✓ l
4.Date Well(s)Completed: S/4 r�41 Well ID# 't/0 R. 4,1r 'ft. 61 7
tj
5a.Well Location: R �t 7 ft.
/-a-Yt- ,7-D n e ft.
Facility/Owner Name � Facility ID#(if applicable) n' rt.22 rr pp �� ft. ft.
611 j r!d4 P_S Q r kr_i. It. It.
Physical Address City,and Zip
gt�- e N f4 r d 21.REMARKS
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.Certification:
3-. X g i.5" N ''- �l , 8 93 R W G t,-x6P Q I 4--z�l
6.Is(are)the well(s):4PPermanent or ❑Temporary
Signature of riffled Well C tra Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 01No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the 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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: /� 24.SUBMITTAL INSTRUCTIONS
1.
9.Total well depth below land surface: T�� (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(200'and 2@100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft') Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"l
11.Borehole diameter: 4//" (in.) 24b. For Infection Wells: Copy to DWR, Underground Injection Control(WC)
�^ Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: r0!u-r�/ 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) / county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: t 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) _9 Method of test: G_l r
13b.Disinfection type: Gl ) d r i y1(✓ Amount: G GL-,S
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018