GW1--05703_Well Construction - GW1_20240920

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: ]]. ,
" '• r.jeo /tfVee`6 14iWATERZONES' '.:11 _ ..
Well ntractor. Name FROM TO DESCRIPTION
.A1s? a -A 7/0 ft. /b ft. 0119 Q
rt. ft. I 1
NC Well Contractor Certification Number 15:'OU TER CASING(for multi-eds diwells):O R•LINER(fa cble)
'
rs 1.6611 Q/2d a A(`Jp/f lU C. FROM TO DIAMETER
ITHICKNESS MATERIAL
Name Oit' GO f. la bL1pn_i -PVC
1 3 (2 _16S INNER CASING'OR--TUBING(geothermalel aooA)
2.Well Construction Permit#: I FROM TO DIAMETER THICKNESS MATERIAL, '
List all applicable well construction permits(i.e.UIC,County.State.Variance.etc.) — _ • ft I; in.
3.Well Use(check well use): ft ft. iI' in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DM cipal/Public p, 8, ija.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft ft iia,
Industrial/Commercial QResidential Water Supply(shared) . 1:18 GROUP�: .- ;;; _:
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: C ft- ft. i
Monitoring Recovery ft.�� it h►fl rt''n r' ' ""'��
Injection Well: �_ _ _ it fa.
Aquifer Recharge OlGroupdwater Remediation 19:'SAND/GRAVEL-PACIC(If applicable).
Aquifer Storage and Recovery QSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer --20.DRILLING LOG(attach additional sheets if nreeccvy)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION(actor,hardness,soiUrodc type,grain sin etc)
4.Date Well(s)Completed: 9" Y a r Well ID# ft' /03 ft. 6%,. �•?j P7-7--�
5a.Well Location: !G. ft. a&s ft. 6'A4'yY' -.--,
C�la'�� as / .. ft. ft �I _„ v-
Facility/Owner Name Facility IDS(if applicable) S. ft
Ad
9 P /7/ 7e,�lei -P �� f. sEP 2 n1Z4
Physical ss,City,andZip ft. ft. Ifffor;;..1;{jg.c; ;ir. r.
4 /[//y - 21.REMARKS LJ:C.sifI�':ix e
County i Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r� G r�
(iffwelll�field,one lat/loing suffficient) r� 22.Certification: a� D al,- Aj
J✓ /9�OtYLo N Val / 7520/ Wfreet C "�
6.Is(are)the well(s) Permanent or [}Temporary 1.
• of Certified Well Contractor 1 Date
TTT��T By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: [JYes or ONO with ISA NCAC 02C_0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
11this 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 ofthisform.
23.Site diagram or additional well details:
8.For Geoprohe/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 INSTRUCTIONSI
9.Total well depth below land surface: 0 (ft:)
For multiple wells list all depths ifdjferent(example-3Q200'and 2@100') 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following: I
i
10.Static water level below top of casing: 3 o (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: L '� (in) 24b.For Iniectiion 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: C \.A_ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) l!
Division of Water Resources,11Uuderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Method of test• �; $13a.Yield(gpm)
L( � CjQ c�(•��,� 24c.For Water Supply&Infection Wells: In addition to sending the form to
/ the address(es) above, also submit l one copy of-this form within 30 days of
13b.Disinfection type --' Amount: � Gt L a completion of well construction¢o the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resource's Revised 2-22-2016