GW1--05971_Well Construction - GW1_20241009

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only �,"`p"
1.Well Contractor Information: 1
3tPr.jeO - - f7t(6ce 06 14.WATER ZONES' ' 1 ._ _ i-.
Well ntractor Name FROM TO DESCRIPTION
.W a _q ft. ft.
ft. ft.
NC Well Contractor Certification Number -15.-GUTER CASING(for multi-cased wells)_ORLINER`(if apIMATERIAL
cable)
'7. r W a/?d any ULC.
lSCI.(-1 FROM TO DIAMETER THICKNESS
Co,,.., Name 6/ ft. 6a ft. lo. 5ni a, -w__
.'16INNERCASINGORTUBING"(teothermai:closed-loop) --._
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL"
List all applicable well construction permits(Le.UIC,Count};State,Variance,etc.) ft. ft. ' in.
3.Well Use(check well use): ft. ft. is
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural °M icipal/Public ft. ft. 1 in.
Geothermal(Heating/Cooling Supply) WResidential Water Supply(single) ft. ft. I in.
Industrial/Commercial '°Residential Water Supply(shared) °18.
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft
9.S. ft. �`n 1-1:lc_ t d
- - Monitoring °Recovery ft. J ' ft.
Injection Well:
ft. ft.
Aquifer Recharge °Groundwater Remediation
:19:,SAND/GRAVEL'PACK(if applicable).
Aquifer Storage and Recovery '°Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test °Stormwater Drainage ft. ft. '
Experimental Technology °Subsidence Control ft. ft.
i
Geothermal(Closed Loop) ,°Tracer 20:DRIIaINGLOG(attaeh'additional sheets ifnecessary) :.....`.
Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sofUrock type grain sire etc.)
Q ft.
So ft• te-ed cis,/
4.Date Well(s) stry �/ Well Completed: �/'�7 ID# so ft• 62 ' 6%0~4'74-
5a.Well Location: (j a. ft' e)45 ft. 6;c:4t e
Giv U J t "�
80l/ 0 O9 O I ( ft. ft. c m.',t.``t.e 7i.; f;-.,.,;.-'ti
• .+.... s.�: / I.., 1'
Facility/Owner Name Facility ID#(if applicable) ft. ft. ,
S W 4r47 fr/t'let LA 805Ceete/CeV4Y0/6 ft. ft. U C T 0 9 2024
Physical Address,City,and Zip ,, :_
GG/ 1r. 7yr�- -ra
t? z1.REnIARxs r.,.,�:. .,:t;�
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r1�
(if well field,one lat/lon is sufficient) (,/ 22.Certification: ca(4 is - 4
___ 3`17gliCSO N 67° // Sid3O w A 4' ' '",y
6.Is(are)the wells) Permanent or °Temporary G �e�/ t
ofCerti ed WellContrac r
By signing this form,I hereby cert1O that the well(s)was(were)constructed in accordance- -
7.Is this a repair to an existing well: °Yes or E No with 15A NCAC 02C.0100 or 1SANCAC 02C.0200 Well Construction Standards and that a
If this is a repay,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 else attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 0
For multiple wells list all depths if different(example-3Q200'and 2®1001 (f t') 24a. For All Submit t(iis form within 30 days of completion of well
construction to the
he following: i
10.Static water level below top of casing: as-
(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: 'W. (in-) 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: (]>.A.l ' construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,)Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) a 0 Method of test: Cq�_Q1,F r(T- 24c.For Water Supply&Infection 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•F`'t _ Amount: 3 Cd's 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