GW1--05283_Well Construction - GW1_20240906

Lr rI rl I VI I I I
WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Welll Contractor Information:
1.11 f VA.Hit)) 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
n `) ft. S j R. j t
LL\\ `7 ft. � 7,.) ft. 9�''' (0,1
NC/// Well Contractor Certification Number / ((�� IS OUTER CASING(tor malti�iiteil wells)OR LINER(if a able)
LI �j,- / . /i t (/( V J� ( J r p t j I �( FROM TO DIAMETER THICKNESS MATE®RiAL
omi a y k YJ f{tJ J J 1 i �/r l l I 1 1 ft. (j'] ft. ��1�( in. t �l
Company Name IJ 1 Ao
_/ /p� \ u 16.INNER CASING OR TUBING(geothermal elesed-loop)
2.Well Construction Permit#:V'j U ir'V[« , ((I'll3i,.18 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. U1C,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): it• ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
0Agricultural 13Municipal/Public ft. ft. in.
OGeothcrmal(Heating/Cooling Supply) IDResidential Water Supply(single) ft. ft. in.
0Industrial/Commercial 0Residential Water Supply(shared) 18.GROUT
F./Irrigation FROM TO IATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ;t) ft. 2'C) ft. i 1 1.}•I.t�1
Monitoring DRecovery ft. ft. Tito
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salini Barrier 19.SAND/GRAVEL PACK(if applicable)
tY FROM
TO MATERIAL EMPLACEMENT METHOD
Aquifer Test �Stonnwater Drainage ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) [Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) (explainFROM TO DESCRIPTION(color,hardness,soil/rock type,grain sire,etc.)
( g/ g Other under#21 Remarks) ft. ft.
1 � �
7 n`•{ 7
4.Date Welt(s)Completed: I. 1 v i Well ID# Lif ft. / ft. csAa.. .
y, )
Sa.Well Location: ft. ft.
iA' 1 a ri--.. 6-, ft. ft.
Facility/Owner Name Facility iD#(if applicable) ft. ft. •` ►.�, ✓ 1�,,
S 7 I UI.{.)C,r8 k ed• 4%1v.IJ'l M 17W ..iv ft. ft. S E P 0 6 2024
Physical Address,City,and Zip t r� (� �/`j ft. ft.
S 1i4 7�t k� 1(( 00-7 1-!l -QC.3'P 21.REMARI{S lath her Fl)rt ,,m- ns tut
County Parcel Identification No.(PIN) v
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) (� 22.Certification: i `�
(y�t`� N _ D L,E.'IlU5 W ( ��1AJ . ! 71 I ZLi
6.Is(are)the well(s)CiPermanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cergft'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or fNo with iSA NCAC 02C.0100 or 15.4 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:
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 same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: L...`1-3 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(0200'and 2@/00') construction to the following:
go10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If wrier level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:U.'((...>i,t (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
i7 i above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 1- <t.ki.11 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) I 0 Method of test: `��},.i'((,
24c.For Water Supply& Injection Wells: in addition to sending the form to
j�f t ( the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: T t Amount:� " .VAS 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