GW1--05072_Well Construction - GW1_20240827

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
.{j-$lit -f R( ed FROM
F TO DESCRIPTION
Well Contractor
�Name ft ft.
ft ft.
NC Well Contractor Certification Number 15 OUiR CASING for multi-cased )OR€INER(If applicable)
F,\s k ,,c/`n-, 0/r Y 9 ,,, ;
f / FROM TO DIAMETER THICKNESS MATERIAL
ft R, in.
Company Name aTlr:;$+E CASIii1G'OR'FI!BING( the!'mal a edaoop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft i.(v v L
List all applicable well construction permits(i.e.L/IC,County,State,Variance.etc.) 4 3 ft ��
ft ft in.
3.Well Use(check well use):
II—SCREEN '
Water Supply Well: FROM TO DIAMETER SLOT THICKNESS MATERIAL
Agric urai OMimicipal/Public '‘.0 ft- `l.? ft* 2 ia' y 0 3 v La, p'/G
Geothermal(Heating/Cooling Supply) °Residential Water Supply(single) ft ft-
IndustriallCommercial °Residential Water Supply(shared) GRDBT
Irrigation FROM TO MATERIAL EMPLACEMENT/METHOD&AMOUNT
fe- tp ft• C-e,r.,�r. - p,✓Ar,4
N Water Supply Well:
onitoring °Recovery &' ft f' ft .-i J-1 pii/
Injection Well: ft ft
Aquifer Recharge °Groundwater Remediation AfltliffilfeatiORKETACIC(>{appilwblc)
Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIALEMPLACEMENT OD
cc 10 ft / 10,e��
Aquifer Test QStormwater Drainage —
Experimental Technology °Subsidence Control ft. ft.
Geothermal(Closed Loop) °Tracer ` = z>>ari3faecesscry)
FROM TO L bESCRIPTION(color,hardness,soir/roek type,mid-size,etc)
Geothermal(Heating/Cooling Return) [Other(explain under#21 Remarks) 0 fe• . f• • i B e a c i
-7,3-2t -fii. �� 1 C.
4. tr Well(s)Completed: Well ID# —r--
ft. ft.
5a.Well Location: ('.
Ii-fh�!l4.. 1A-ft-f-6'-- f-, . -
Facility/Owner Name Facility ID#(if applicable)
f(V° ' Uc\i3i',t,; A/ t_�Je.- ;- ,,, - 27/3 Z — — i 2 7 ?e;
Physical Address,City,and Zip — .
Cc2 w.i,-_ -----
County Parcel Identification No.(PIN)
•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: L_. -
(if well field,one lat/loug is sufficient) 22 Certification:
6 . 1`t32. 3 N — i6r4;,s3z-I W %----- 7��` ' `
i of Certified ell Contractor Date
6.Is(are)the weIl(sermanent or °Temporary
8y,yj7nntg this form,I he.thy certify that.he (s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or No with ISA NCAC 02C.0100 or ISA 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 be_t provided to the>r ell owner.
`repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the sane
construction,only 1 GW-1 is needed Indicate TOTAL NUMBER of well:'
consGudion details. You may also attaci.additional pages if necessary.
&i- z SUBMITTAL INSTRUCTIONS
9.Total sill depth below land surface: (h-) 24a. k'or All Wells: Submit this form within 30 days of completion of well
For,rn*Sip le wells list all depths if different(example-3 a200'and 2@I00') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resonrcra,Iai rmation Processing Unit,
If water level is above caring,use"+" 1617 Mai..Service Center,Pa eigh,NC 27699-1617
11.Borehole diameter. cr (In.) • 24b.For Injection WAS: In audition to ser ling the form to the address in 24a
above,also submit one:copy of this form wi aut 30 days of completion of well
12.Well construction method: t rt,e/ fk5 e'�7 construction to the follc-wing:
(i.e.anger,rotary,cable,direct push,etc.)
Division of Water Resources,Undergr(and Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Well: In addition to sending the form to
the address(es) above, also submit one ;opy of this form within 30 days of
13b.Disinfection type: Amount 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 Resource ' Revised 2-22-2016