GW1--06532_Well Construction - GW1_20241101

WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only: !
1.Well Contractor Information:
K( ,) V`-'psi/,0 14..WATERZONES
Well Contractor Name FROM TO DESCRIPTION
,2_� 15 0 ft. 1 LI 5 ft. /1
i f i6 ft. 3,^ ft. p D j� co,,,
NC Well Contractor Certification Number —T 1�-' pl. '�"1 c� yjJ"{mil
orary_
,ry //n�� 15.OUTER.CASING(for multi-c' 'eitiiii ls)tOR:3dNER(lfap'lIcable) -v 61/6i�; t pPp P{'c. (sorrip� ` i.. ii v' c FR0114 TUDIAMETER I THICKNESS MATERIAL
Na (A/U Plitt/ I 6r/!1Y-� FV J ® IL 7 fL (�r I in. {�t/�
Company Name (o t4 r V
j 16-INNPR,CASING`OR"TUBING`(eothermal.closed=loop) '- - -. -- - - -
2.Well Construction Permit#:n TV-3 [ [f FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. U'C,County,State,Variance,etc) ft. ft. ' in.
3.Well Use(check well use): ft. ft. in.
17SCREEN Water Supply Well: -
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
*Agricultural fMunicipal/Public ft. ft. in.
X;Geothermal(Heating/Cooling Supply) OResidential Watcr Supply(single) ft. ft. in.
**Industrial/CommercialDResidential Water Supply(shared)
,.1 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN'L.
Non-Water Supply Well: 0 ft. W ft. 2t!1 t iY E i.41
l \., t, ...E ` V:--
*Monitoring 0Recovery ft. ft.
Injection Well: N()V �� 1 i(]7,i
ft. ft. `
1111Aquifer Recharge 0 Groundwater Remediation
�iAquiferStorage and Recovery �^�Salim Barrier 19:SAND/GRAVELPACK(ifapplicable) _ _.• tt' �'.c.y - t-z.i} r'.
F.--1' tY FROM TO MATERIAL EMPLACEMENT METHOD
NI Aquifer Test 0 Stormwater Drainage ft. ft.
s-Experimental Technology DSubsidence Control ft. ft.
*Geothermal(Closed Loop) D Tracer .20:DRIIiLIN'G I OG-(attnel aitditiorialiheets ifneeess
al Geothermal(Heating/Cooling Return) ri Other(explain under#21.Remarks) FROM TU '-
DESCRIPTION(rotor,hardness,soil/rock t pe grain size,etc.)
//')), �y ft, 30 ft. CA
p O ,
4.Date Well(s)Completed:`�7\ ..put Well ID# ft. 3.6/ ft. yak.>�Ot 'tA �i
5a.Well Location:Yilarl ft. ft.
tale 1 ea lAs i rrab'f;." ft. ft.
Facility/Owner Name Facility ID#(if applicable) It. ft.
1 1-e.i 1 ' +Dr. WWuj n&stAle., 2 -itp ft. ft.
Physical Address,City,and Zip i) ft. ft.
. I AIJ'fliO
County V Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,y /Bonne lat/long is sufficient) 22.Cer' cation: (� f
35. 2- N - /sZ•g37 W yCitifter..-...***-- CIizij"H
6.Is(are)the well(s) Permanent or Temporary Signature of Certified Well Contractor Date
77tt" By signing this form,I hereby cert f'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or No 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 an 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:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1
SUBMITTAL INSTRUCTIONS '
9.Total well depth below land surface: i.3.P5 (ft.) 24a. For All Wells: Submit this form within 30 da s of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@100')
100') construction to the following: y p
10.Static water level below top of casing: Lk.) (ft.)
Division of Water Resources,Information Processing Unit,
limiter level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: CP f i (in.) 24b.For Iniection 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: 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 Mail Service Center,Raleigh,NC 27699-1636
�j , t 1
�
13a.Yield(gpm) 1 Method of test: 1-An 24c.For Water Supply&iniectitin Wells: In addition to sending the form to
I , the address(es) above, also submit'one copy of this form within 30 days of
13b.Disinfection type: '�'`I'�I Amount: S. completion of well construction to'the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources , Revised 2-22-2016