GW1--06547_Well Construction - GW1_20241101

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
1 Y/Avt S el Wile, ,14:WATER`zONE3 .'z s
FROM TO DESCRIPTION
Well
''Contractor Name 0 frt. �/�f� It.
` /,''}} ft. ft. V I '
NC Well Contractor Certification Number
15:'OUTER:CASING(for riulti;eased>wells)OR LINER'(if.'dp limbic) . .
a tr �il^ � Wen ' [2u�p,WY to C�
0 ft.` FROM l fl fi l i m A i CR THICKNESS D AL
! /V
Company Name
• •16:I1�iNER'CASINGQR:TUBING:(peotherm>ll�losed>loop) ;.-...
2.Well Construction Permit#:1/0(i .
r�r � (�(�d��f FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(.e.UIC,Couny,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in,
Water Supply Well: 17`SCREEN ...
FROM TO DIAMETER SLOT SiZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) 1117 Residential Water Supply(single) ft. ft. in. ,
Industrial/Commercial DResidential Water Supply(shared) I8._GROUT.
Irrigation FROM TO M MATERIAL EMPLACEMENT ETHOD z AMOUNT—'
Non-Water Supply Well: 0 ft.
2 ft. `•, 1 „ .:
Monitoring DRecovery ft. ft. NO V 0 1 2024
Injection Well: ft. ft.
Aquifer Recharge 0 Groundwater Remediation .
�1,9:'SAND/GRAVEILPACIL(if•applicable) , .`y .1-n'
Aquifer Storage and Recovery 0Salinity Ranier FROM TO MATERIAL EMPLACEMENT ME'rHODJ
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology 0 Subsidence Control ft. ft. •
Geothermal(Closed Loop) Tracer • •:20'DRILL•INGL'OG(atta'cb:addttional sbeets:ifuecessa '
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) riOther(explain under#21 Remarks) �)
9J ft. i Y ft. , r
i7 t eJ I!c '
4.Date Well(s)Completed:�j e����� Well>D# '']� ft. I�S ft. o� ,�
5a.Well Location:
V ft. ft. V
� (� ft. ft.
7"iL It i p rtor
ft. ft. IFacility/OwnerNaame FaciilityID#(if applicable)
4/2.!--1 Conn 6 relic. • { cuivieNA Ile.217
ft. ft.
ft. ft.
Physical Address,City,and Zip
�J
‘.,' )0C- i C3�1.)� '(Jl Z1:REMARI(S: .t.
County 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:
g 36 07, ,---A.-- _ 15 1 zs lig
Signature of Certified Well Contractor Date
6.Is(are)the well(s) Permanent or DITemporaly g
By signing this form,I hereby certf.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 NCAC 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:
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 11 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: igs (ft,) 24a. For All Wells: Submit this fonn within 30 days of completion of well
For multiple wells list all depths if different(example-�3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: (YV (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: LO I q (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
r-Ota
,n above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 1/ (4 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: �f 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) t Method of test: ii tiS 24c. For Water Supply&Iniection.Wells: In addition to sending the form to
�,{ •• e,� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: MIA 1 i"� Amount:�U 1 .S completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016