GW1--06528_Well Construction - GW1_20241101

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
1
POO{V muoto14:WATFIt;ZONES ;i
Well Contractor Name FROM TO DESCRIPTION
. i .
1 ft. 30 ".
�� `1 ft ft.
NC Well Contractor Certification Number 15.OUTER CrtSING(f6r..'.utulli case'd,ivells)iOR.LINER:a"ifap 'cable)
1/ Imo, y�� /� Well
(� g+ },� Q FROM TU DIAMETER' THICKNESS M1ZAL
k It
Y AP..d 1.P1 13f 1/ 1-1 S Well 4 Pump 1 tA) ! 116 ft. f e f ft. p/} /3 fj in
Company Name �Yrl� ll/ &�-t
��� �big
l INNER'C ASIVG OR:1 UB1NG(geothermil'ciosetl=loop)
2.Well Construction Permit#: t t;� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Counga State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: :I7.;SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ' QMunicipal/Public ft. ft. in:
Geothermal(Heating/Cooling Supply) PResidential Water Supply(single) ft. ft. in.
Industrial/Commercial OlResidential Water Supply(shared) Is GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT•METHOD&AMOUNT
Non-Water Supply Well: Li ft. 20 ft. j,.-0,1 �� _ n S. -)
Monitoring E.:iPRccovery ft. ft. V
Injection Well: NO 0 3 2O24
ft. ft.
Aquifer Recharge DGroundwater Remediation
19 SAND/GRAVEL'PAC1f(ifapplieable) ' 1)' - .7?n^x•-i -.:, !t,,.
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMFN METHOD,, o ""
Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology E3 Subsidence Control ft. ft.
.Geothermal(Closed Loop) � �Tracer :20DRILLING:LOG:(attach addittonaFsheets�.ifnecessa=v) - -�� _ .:•.
FROM TO DESCRIPTION(calor.hardness,soil/reek type.grain size,etc.)
Geothermal(Heating/Coolinng��Return) Other(explain under#21 Remarks) ft. U.a rt. ��.
4.Date Well(s)Completed:U1\. ,2(-.!g Well ID# ft. 375 ft•
kif itt
5a.Well Location: ft. ft.
ft. ft.
aF cility/Ownnel-Name FacilityID#'(ifappticable) _ ft. ft. .
Vkino ft: ft
Physical Address,City,and Zip ft. ft.
S1t REMAltISS": ,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) ,,y 122.Certification:
63 . g N -53 q�..✓lO w z
6.Is(are)the well(s): Permanent or i:;Tem ores Signsjr.u:L__
of Certified Well Contractor V Da c
P ry
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or (. Vo • with 15A NCAC 02C.0100 or 15,4 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 1121 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 QW-1 is needed. Indicate TOTAI.NUMBER Qfwells construction details. You may also attach additional pages if necessary.
drilled: 9 /) SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: '/._7' (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@l00`) construction to the following:
10.Static water level below top of casing: j �,� (ft.) !'
Division of Water Resource's,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
( nil"
n
11.Borehole diameter: t g I.-I (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
y above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 1
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: (� 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) i 2.-- i/V (Method of test: 24c.For Water Supply&Infection''yells: In addition to sending the form to
j, the addresses) above, also submit i one copy of this form within 30 days of
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13b.Disinfection type: i'1 1 !`"1 Amount:LID J1S completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnviromnental Quality-Division of Water Resources , Revised 2-22-2016