GW1--05339_Well Construction - GW1_20240906

II 11111.111J1.111
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
V-Obtrl YJ OM 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
(t. �� ft. r
9(-4 li f ) ft. f IPS ft. Z. el
NC Well Contractor Certificationl Number d+ Rime (A(p /L IS.OUTER CASING(for multi-cas wells)OR LINER(if hie)
( 1 A t,r■ rS li Y � 1 V v 1 Irit4.- FROt ft.
T ft. f) A(f t 1,R in. THICKNESS iM TERIAL
tvt i Company Name 0/ �y l`7
` `
�j` 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:v. L.21�q`t'Utl( 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): it. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
Industrial/Commercial EaResidential Water Supply(shared) 18.GROUT ,,.
irrigation FROM TO ATERIAL EMPLACEMENT METHOD&AMOUNT
NOD-Water Supply Well: 0 ft. '7 0 ft• 111 it
Monitoring 0Recovery ft. (� ft.
injection Well: it. ft.
Aquifer Recharge 0Groundwater Remediation
19.SAND/GRAVEL PACK Qf applicable)
Aquifer Storage and Recovery 0 SalinityBarrier
FROM TO MATERIAL EMPLACFMF.NTMETHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) 0Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sire,etc.)
Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) o ft. ft.
4.Date Weli(s)Completed:S /' 4____ Well iD# � ft. i`?S ft. ,1((��lt��
5a.Well Location:
ft. J ft.
-Don da.VA n ft. ft.
Facility/Owner Name /,,'.1 S� V��t��/1C1Fwile,
acciliityiD#(ifappllliicaa�ble/ ft. ft. t� 1
25 (�. v YAA/ 1Jk 1 :t !,Y 1 leiv bit ft. fr. `\J L.'`J i,t ,l
Physical Address,City,and Zip ft ft. SEP
,,+ (� G y 0 6 ZfiZ4
�COnniYk i✓)^k 3-'4)� 13 �I.REMARKS
County Parcel identification No.(PiN) IMo:it.alit+n Prrr aMie'tni✓1:
04•101110G
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. ertifcatlon:
3S-Uti0 N -8 2.-- W - 4l�/zCI
6.Is(are)the well(s)rPermanent or Temporary signature ofCertifiied wGVI1C
actor Date
Br signing this form,I hereby certifi'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or ❑No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Constntclion Standards and that a
If this is a repair,fill out known well construction information irmation 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 details. You may also attach additional pages if necessary.construction,olly 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Ks1 (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(0,200'and 2@100') construction to the following:
r
10.Static water level below top of casing: 40 (f14 Division of Water Resources,information Processing Unit,
limiter level is above casing,use"" tr 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: l/Yn ` (in.) 24b.For infection Wells: In addition to sending the form to the address in 24a
I above, also submit one copy of this form within 30 days of completion of well construction to the following:
12.Well construction method: construction vi
(i.e.auger,rotary,cable,direct push.etc.)
`f
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
C
13a.Yield(gpm) J Method of test: _p' CwILT! 24c.For Water Supply&Injection Wells: in addition to sending the form to
�a +,, the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 4-1f1-1 Amount: �3 1 L� ✓� 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