HomeMy WebLinkAboutGW1--06319_Well Construction - GW1_20241022 . IJ
WELL CONSTRUCTION RECORD(GW-I) For Internal Use Only:
1.Well Contractor Information:
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Well Contractor Name A
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NC Well Contractor Certification umber :r•1 ;OPf'rgla Ils(fr,`�fo" Inta"iti*A 3 yyy�l1�fOr '(tf ii- yaQylf arl`'' �'W'�"<".;
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FROM TO DIAMETER THICKNESS MA
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Name14 g' eiirlTuser> ilowlr �'.
2.Well Construction Permit#: ( �'�� ` l a ;®�` FROM TO DIAMETER
R in � MATERIAL
List all applicable well conshuctton per mots(l.e.U C,County,State Varlal etc.) ft' ft. 1
3.Well Use(check well use): t �;y :.may+, ,.
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Water Supply Well: FROM TO DIAMETER . SLOT SIZE THICKNESS MATERIAL
Cl Agricultural D unicipal/Public ft. ft. In.; •
CIGeothermal(Heating/Cooling Supply) iesidential Water Supply(single) ft ft. in.:-
Dlndnstrial/Commercial °Residential Water Supply(shared) _-' az"r. .: ?,r is- ,w"'::�s , .q. tip r•" .``t t,
.T'Bi�GI�I•`�'�,.-,'{r�.tti .. 'tt,.,..\. .�`..�;a..,ti��"ati" � :✓.-, x ..?t:x�l..r7�.��'4�.`i r..�..,_.a;
DIrrigation °Wells>100,000 GPD FROM TO MATERIAL �_ DIPLACRMENT OD&AMOUNT
Non-Water Supply Well: 0 ft. , .dd� ft �1As,1< q multi
i
[]Monitoring °Recovery it ft •-J pica
Injection Well: ft. ft. ' "
0Aquifer Recharge [Groundwater Remediation t�9K5AdfAirriaCtiFAilcti bY s.,., , } „•;1 �� =m .- t
°Aquifer Storage and Recovery OSalinity Barrier FROM TO V MATERIAL , EMPLACEMENTMETHOD
°Aquifer Test ClStotmwaterDrainage ft, ft.
DExperimental Technology ❑Subsidence Control ft. ft.
°Geothermal(Closed Loop) °Tracer ,?b81 \L' ( ,, i.:,,t' ,,
ie zutilitiiitia'tl �a`&e�;se�i'�Y�.��'��•� ..��: :�'�•�§;�,;
FROM TO DESCRIPTION(color,baritone,soilkock type,ono size,etc.)
°Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) ft. ® GI Q
4.Date Well(s)Completed:.-!1-li Well W# ,gyp ft. f 110f t. ,¢q note rc f8c:d
ft. ft.
Sa. ell Location:AA/f0— ! <. ,
- PO i5 IL. ft.
4 � r .0 or.' ' i
c ' ID#(if pplicable) ft. ft .t c c-,'.."`'
Facility/Owner N OCT2 `•
11 6 Woo&rizA
Neiltdh, ..1(903 . ft. ft.
(� - ft. ft. Ir, ,
Physical Address,City,and Zip /p� r ' '
C9 /i 1 7(�0)-a76, '�;irtvg,..1:9 ." iri;'�' YT,z'.`.10-fi''.s `�.;s::'��xgt,��,'"'.Y7momo
Comet, Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/lonng is sufficient) 22.Certification:
N w � / Tll-P1
(Permanent or °Te or Si l,F of Certified Well Contractor Date
6.Is(are)the well(s): mP m'y
By stgntng this form,!hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or Iliko ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,ff 1l out known well construction information and captain the nature of the of this record has been provided to the well owner.
repair under#121 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geopxobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info.
construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER.of wells (add'See Over'in Remarks Box).You may also attach additional pages ifnecessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 SD (it.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifeliJ)erent(example-3®200'and 2®100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 0 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwaterlevel is above casing.use F'+'A I
r� E, C i
11.Borehole diameter: {iL 1 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: a (r f A 7 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
1
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells produelni over 100 000 GPD:Copy to DWR,CCPCUA
b tow Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: ! 1
a.
13b.Disinfection type: t i Amount: I(
North Carolina Deoartment of Environmental Quality-Division of WaterResources Revised 6-8 2018