GW1--06187_Well Construction - GW1_20241021

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use only:
1.Well Contractor Information:
.-'t?r.,S6o -741i- C1 G 14..WATERZONES ' I
Wep ntractorName FROM TO DESCRIPTION
CQ a -A Id f. 13o ft 6. i(/M
NC Well Contractor Certification Number °2�'U ft. yo ft 56 6-'
41
�J�/ �J F/�(�. ��j�e'/�./� /J 15'OUTER'CASING(for irmlt cased`weUs).OR-LINER"(dap`licable) ':
� al?d ,'Vn p`�C/U U(�C i l�LC F 7M ft. 7 R.TO DIAMETER i� MATERIAL
bNanir
e ` 9 I5THICKNESS
I�i al �ttC
( Ll L/ I C 16:INNERCASING'ORTURING(peothet•'uinl.dosed400p)_ ,a ` ...
2.Well Construction Permit#: I ff J 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): ft. ft. in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public it it hi.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) it ft in.
Industrial/Commercial oResidential Water Supply(shared)
- Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft ft.
Monitoring - � - _ �� ��'�i nr_ I�G1XP� 1 J)
_Recovery ._ -- - .- _ __ ft _ ft
Injection Well: -..---
ft. ft.
Aquifer Recharge DGmundwater Remediation
19 SAND/GRAVEL PACK(if applicable) `_
Aquifer Storage and Recovery OSalinity Bather FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test oStormwater Drainage ft. ft
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) DITracer 20.DRILLING LOG(attach additrooafsbeets if necessary)
—Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiVmck type,grata size etc-)
l ` o ft /5 ft. RicaC7¢y
4.Date Well(s)Completed: L(2/� Well IDi 5,5 ft' rf 7 ft ,a(Cr^`r7-<_
5a.Well Location:/� 9 7 ft.
d�/.c ft. G',V ,",—r
L12WAp A0a ft. ft
Facility/Owner Name Facility ID#(if applicable) ft• ft• b-� .:. --`_
tid st,� 5,/,b 5/v 11 ft. ft - -- •,'iL::: - ,:, ;
Physical Address,City Zip ft. ft. U C 12 12024
6)---.0<`-M 21.REMARKS
J ! fl iia.�r•C:c.-, :J-r r`✓-. ,•a lis..YA
County Parcel Identification No.(PIN) r'"..T..,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: c� G r�
(if well field,one lat/long is sufficient) / / 1.� 22.Certification: oL to D o.. - A l�j 1�
75-°()0(0 N ° r0 !
6.Is(are)the wll(s) Permanent or ()Temporary L �'�t LofCemfied W ,/ell Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
- '--=7.-Is this a repair town existing well: IlYes orElio' - with ISA NCAC 02C.0100 or ISA NC4C 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#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 also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: '' l y )/ (I' ) 24a. For MI Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3Qa 200 t''aandd 2Q100') construction to the following: 1
10.Static water level below top of casing: C 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: L1 1"#-• (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
1� above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: �� 1�} a>,.5\.l..-1 construction to the following:
(ie.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) GO Method of tes � )Q L'r,e— 24c.For Water Supply&Injection 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 4:-' Amount: c completion of well construction to the county health department of the county
where constructed.
Ferro GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016