GW1--06530_Well Construction - GW1_20241101

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
(1.Well Contractor� Information:
r°I/5I in I pJ.e,i( IA:IVATER'ZONES .
""'� FROM TO DESCRIPTION
Well Contractor Name
Z`-i L 6 1 oS :::
wi
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///NC Well Contractor
cCertificationNtmber r '15:GUTER CASING'(fOr-Multi,cased-Welii)OR LINER(if ap licable). .
/ ����� `� k,� (IOW
j RAW,
_ r j q t { �yn/t FROM TO DIAMETER THICKNESS I1L+,TERIAI.
`� !lJ (.t/,g a >�(.K/1 �'l i i'l/l� L�(f J r 71�• y� ft. I i tG t f , in. (G!t�•
Company Name J V �{�) G t)��./;.
r ti i [ r 1 {`�� ..:16 INNER.CASING OR TUBINGageothermai closed400p)
2.Well Construction Permit#:1 t/�j'J [Ji )b L t FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State,Variance,etc) ft. ft. 1 in.
•
3.Well Use(check well use): ft. ft in,
Water Supply Well: FROM TO DIAMETER SLOT SIZE TAICICNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. in.
Industrial/Commercial Residential Water Supply(shared) •18.GROUT s
in'igatiem FROM TO MATERIAL 1 EMPLACEMENT METHOD&AMOUNT-_1\
Non-Water Supply Well: 0 ft. l it. beA-Ivnr '''t•.,. �,`a
Monitoring ElRccovcry . ft. ft. ,e t`'f` NO V r) T ;j ,
Injection Well: ft. tr.
Aquifer Recharge DGroundwater Remediation Ii..`,.r,7
• '19 SANDIGRAVELPACK(If'applicable) '=' ' " U!:?t
Aquifer Storage and Recovery 0Salinity Barrier ' FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStonnwater Drainage ft. ft.
Experimental Technology E3Subsidence Control ft. ft. .
Geothermal(Closed Loop) OTracer 20DR1TLINGIOG'{attncti'addlilonaLsheets-ifneces§arg} ,. ,. .
'FROM TO DFSCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return). DOther(explain under#21 Remarks) ft) ft. �� ft.
r✓ i
/� CCr('' I ft. ft. t
4.Date Well(s)Completed:-!)� 2-4, Well 1D# ki s g-
ft, ft,
5a.Well Location:
YD 10011 t 41er ft. ft.
Facility/Owner Name Facility lD#(if applicable)
ft. ft. 1
Z4 Ell MO A' Ln. 0,6 ►l he. 7. l (.fi ft. ft.
Physical Address,City,and Zip ft. ft.
21.REMARKS .
County t Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:(VUJ'41r
6.Is(are)the well(s)JPermanent or jTemporary Signature of Certified Well Contractor ate
By signing this form,I hereby certify that 1/re well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: fYcs or EINo with 1SA NCAC 02C.0100 or 1SA 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 4121 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: 6 SUBMITTAL INSTRUCTIONS;
9.Total well depth below land surface: 1S5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdterent(example-3@200'and 2@I00' construction to the following:
10.Static water level below top of casing: 140 (ft.) Division_of Water Resources,Information Processing Unit,
.It water term is anove casing.use * 1b17 Mai!Service Center,Raleigh,NC 2 769 9-1 61 7
pp
11.Borehole diameter: 1i l i mot"!r (In.) 24b.For Injection 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: ( tj construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636
'ifj13a.Yield(gpm) Method of test: 5 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
113b.Disinfection type: Amount: 3 4t1o2S I romptetton.of well construction to the county health.department.of the county
where constructed. 1,
1
Form GW-1 North Carolina Depattuieirt of Etivtironmental Quality-Division of Water Resources Revised 2-22-2016