GW1--05285_Well Construction - GW1_20240906

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Will Contractor Information:
1
Woo t`i drip 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name u ft. .` �0f. J7� l ill
,`- 'ft, ft. (t _n
uJ t . �'M
NC Well Contractor Certification Number 15.OUTER CASING(for multi-case wells)OR LINER(if a )
! / r -1 A FROM TO DIAMETER THICKNESS MATERIAL
t't'w'v- � 'i!TVA(\ W W-- f.�( 0 I lids .
Company Name IrIINNER CASING OR TUBINGi l�
iA� �'\� / � n, } (geothermal closed-loop)
2.Well Construction Permit#:Yam`�(3,/(;. -D -21 j ) FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,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 DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) DResidcntial Water Supply(single) g ft. in
Industrial/Commercial QRcsidcntial Water Supply(shared) 18.GROUT
Irrigation FR TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
f ft. 1 ft. �-
Monitoring 0 Recovery ft. ft. i
Injection Well: R. ft.
Aquifer Recharge oGroundwater Remediation
Aquifer Storage and Recovery 0 SalinityBarrier 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) 10 Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiVrock type,grain size,etc.)
Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) f> ft. ./t) ft. (1
fit { 11
4.Date Well(s)Completed: \ (�-I Well ID# � ft. is- ft. I...; 4�4 ✓
t- Ci J
ft. ft.
5a.Well Location:
HiA �-
I�/i ft. ft. - r:, ,
1 - -
Facility/OwnerNamc Facility #(if applicable) ft. ft. L..' ,J Iwo.
k it COI6.111 re . AllotII . "22,11i ft. ft. SEP 0 6 21124
Physical Address,City,and Zip ft. ft.
' ,iYl r-'L l in - sU-Og g S 21.REMARKS hh)r -,�ow crillilitrit(1ak
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Ialllong is sufficient) 22.Cer' cation:
if
6.Is(are)the wells) Permanent or OTemporary Signature of Certified Wcl(Contractor Date
By signing this form,I hereby certifiv that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or rtiNo 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 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:
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: I SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-j33@200'and 2@100') construction to the following:
10.Static water level below top of casing: Llt!l.r (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: Ut (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) (.Jlti'' Method of test:i. v Y j t'a 24c.For Water SUDDly& Injection Wells: In addition to sending the form to
1_ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: .)-k Amount: 1 .1 ay)\ completion of well construction to the county health department of the county
where constructed.
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016