GW1--05342_Well Construction - GW1_20240906

lI IIIII.I VIIII
WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor information:
► n V v1 C0 14.WATER ZONES
FRAM TO DESCRIPTION
Well Contractor Name © ft. �/`,��t. 1 ertyl
1g ft. J✓ft.
NC Well�Co�n/tr�a�ctor(C��eirt/i�f�ica�ti�on�JNu�mber / LOT
11�( _15.OUTER CASING(for multi-cased wells)OR LINER(if cable)
r��(.�' �_ lam■�'r+'� 'G�a� ` r i "� i► �,/• FROMETER
D ft. f ,,j n ft. 11�i TO t'LF in. THICKNESS MATERIAL
Company Name -FAY / ttrll�ly/t`�f
16.INNER CASING OR'FULLING closed-loop)
(geothermal closedp)
2.Well Construction Permit#:WGL UV! - Op 1L�IJ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County.State, Variance,etc.) It. It, in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) MResidentiai Water Supply(single) ft. ft. in.
Industrial/Commercial DRcsidcntial Water Supply(shared) 18.GROUT
irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: VLC) v;et fi ft• ft. r j&.
Monitoring QRccovcry ft. ft. t[��"LI' 11��►►
injection Well: ft. ft.
Aquifer Recharge 0 Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology ()Subsidence Control ft. ft.
Geothermal(Closed Loop) 0 Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiVrock type,grain size,etc.)
Geothermal(Heating/Cooling Return) [Other(explain under#21 Remarks) 0 ft. (If „ ft. (S ,}�
4.Date Well(s)Completed: i.2 i2012L Well iD# r jl n ft. --A,1 ft. c IY Tx l I4K�
` Vt ft. ft. t/f
5a.Well Location:
ft. ft.
�' 1lAcrst�c ►� icii ft. ft.
acility/Owner Name Facility Mar(if applicable) al.�
rft
ia) "(S('D D `141,U le_ -ZY,S0,. ft. ft. `.� �r•'
ft. ft. '-'
/ Physical Address,City,and Zip / r� / SEP
2OIQ
ak,00,0Ynkoe-- Ciii2Ve ,IJ' -Y'3-1G9 21,REMARKS s E P 0 Q
County Parcel Identification No.(PiN) I�i.�fit/i�og
w �A • tin5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ^`♦s�f
(if well field•one lat'long is sufficient) 22.Certification:
6.Is(are)the well(s)�1 j,ermanent or p-�Tem ors St{ypa(urc of Certified WcllYontractor Dace
CFa O P ry
By signing this form,I hereby certifi'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or6No 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 421 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: , '� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /V� ((t't.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-310200'and 2(1000') construction to the following:
10.Static water level below top of casing: -i (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: CO t (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) l Method of test:EtriuA /' 24c.For Water Supply&Injection Wells: In addition to sending the form to
f (� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 17,11 .$ 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