GW1--05701_Well Construction - GW1_20240920

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I'
1.Well Contractor Information:
er.4 0 -'241 1/'p Cl(/
i 14.WATER ZONES.=. • I ! .-- .
Well ntractor Name FROM TO DESCRIPTION
c p a -A &aU& ,3fir/ ft. s (An
ft. ft. 1
NC Well Contractor Certification Number
t WU.(_i l2I[d i'VI rip (/Ll LC,
OUTER CrAQSING(for:multi=cased welis):OR LiNER'(if ap 1letble)
r5 CM S) It. / Rtn. �TEnC[QYEE�SS I MATERIAL
Com Name p / C/ e[ a-r is li ?re-
!/ GI /CO ''16 INNERiCASiNG'.OR.TURIN(C(geothermal coop) 7-
2.Well Construction Permit#: I FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County;State,Variance etc.) it. R. in,
3.Well Use(check well use): ft. ft. In.
Water Supply Well: 1T SCREEN:
FROM TO DIAMETER SLOT SiZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
Industrial/Commercial 'QResidential Water Supply(shared)
Irrigation • FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it ?S ft )91 Cl 1-1 n G f'(EMlr- d t tr)
Monitoring ORecovery ft. ft.
Injection Well:
- ft. ft. -
Aquifer Recharge }Groundwater Remediation
'19 SAPID/GRAVEL PACK(iifapplicablee) .
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test D Stormwater Drainage R. ft- ,
Experimental Technology QSubsidence Control ft. ft. I
Geothermal(Closed Loop) Tracer 20.DRILLING LOG"(attach additional shiers if n scary) -
Geothermal(Heating/Cooling Return) ©IOther(explain under#21 Remarks) FROM To DESCRIPTION(color.hardness,soiVrock type.grain size,etc.)
4.Date Well(s)Completed: V 3o/c2V Well ID# /O ft /se ft /'rPr-7'(--
5a.WellLocation: / /V f' �,?Gt% R' C/'C�(
/4 C'Q/1 /Z-"I/1 e /�il ft. ft
Facility/Owner Name /Y Facility ID#(if applicable) ft. R. t i. ,a„'1! ./ice'j
1 ° Y7 f e2-/sChr,.e/gri dc. 'a ra/‘ ft. ft. SEP 2 4 2024
Physical Address,City,and Zip R. ft.
Cos ti 21.REMARKS Ir,�v;g-.L it'.i: ?rr:^srwz;•-a i,•..
OtioJ1 -9 DWC6100
County Parcel Identification No.(PIN)
51.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r� / r�
(if well field,one lat/long is sufficient) 22.Certification: Q(Q Q. A
75 19 aJ® N ( $7V i w
6.Is(are)the wells) Permanent or Temporary L 'e'�^ofCert"tired Well Contractor Date
•By signing this form,I hereby calf that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: IQYes or No with i SA NCAC 02C.0100 or 15A 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#2l 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
constriction,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: (fh) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3®200'and 2@I00') construction to the following:
10.Static water level below top of casing: c1 (ft-) Division of Water Resources,Information Processing Unit,
If water level is above casing.use''+". 1617 Mail Service Center,Raleigh,NC 27699-1617
t
11.Borehole diameter: Om) 24b.For Infection 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: Q.INA-1 construction to the following:
(ie.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) / S.
Method of test: 'fa i)R tr 1'.Cll 24c.For Water Supply&Infection'Wells: In addition to sending the form to
��/
` the address(es) above, also submit one.copy of-this form within 30 days of
13b.Disinfection type �i 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 Resources, Revised 2-22-2016