GW1--06548_Well Construction - GW1_20241101

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
I.Well Contractor Information:
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Well Contractor Name FROM TO DESCRIPTION
ft ffn ft
' NC Well Contractor Certification Number
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JJ�� ((( is OUTER-CASING(for-'multi-cal.;itiVdllss)110RLIN1R�(Ifap-liable) .. ..
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ln`�I IA FROM TO DIAMETERin. THICKNESS 1 MATERIAL
Company Name l Y 1`t,
,i 4 1 6 INIYER-eli.SDI Olt:TUBING t eothermat eiosed-itiopj
2.Well Construction Permit#: J t-�{1.3j1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pernits.(i.e. U1C,County,State,Variance,etc.) ft. ft. i In,
•
•3.Well Use(check well use): ft, ft. in.
97..SCREEN- . ,4 ''
Water Supply Well: FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
Agricultural ' riMunicipaUPublic ft. ft. in.!:
Geothermal(Heating/Cooling Supply) HiResidential Water Supply(single) ft. ft. in.;
Industrial/Commercial DResidential Water Supply(shared) f8RO11T Y . .
Irrigation FROM TO MATERIAL EMPLACEMENTMETHOII&AMOUNT-'ll
Non-Water Supply Well: ft. ft " 4'--` R e, 4
Monitorin �-6Rccovc
g ry 0fr. tt. NI)V 0 2024
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation [ ,.,.• yr
19.SA b1D/GRA1'EL PACK(If applicable) ".
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test IStormwater Drainage ft. ft.
Experimental Technology OiSubsidence Control ft. ft.
Geothermal(Closed Loop) .OITracer 20 DROLLING;'LOG(a"tfacl additionit7.=sheeli ifneeessa yj . :` .
Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION(color,hardness.soil/rock type,grain size,etc.)
g/ g t Other(explain under#21 Remarks) ft. '� it. (3 9
4.Date Well(s)Completed: E 213ll4 Well ID# 1g ft, ft. 4 Jrc . .� ;
v ft. ft. •aLJr R
Sa.Well Location: ,
ft, ft.
f�15ft3t ' Jy� nt,�P,lG . . _
Facility/Owner_ac Facility ID#(if applicable) ft. ft. IMlle
r ft. ft.
' To-Li 2- Cmis iete.DY. W tr�.s�+(c.� 7.. 1gg� ' •
'W Physical Ad�dr�essrs,City,Q and Zip ')j�� t^� f ( ft. ft.
AG ltigg"'147-b / N ;21 REi�ARKS . .1 .
County t Parcel Identification No.(PIN) .
5b.Latitude and Itingitudein degrees/minutes/seconds or decimal degrees:
(if well field,one lot/long is sufficient) 22.Certification:
3S1 cii N ~�its w '
6.Is(are)the well(s) Permanent or Tem ora Si aturc of Certified Well Contractor Dat '
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 13BNo with 15A NCAC 02C.0100 or 15A 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#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 1 cl
W-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I !! '',�,��!! SUBMITTAL INSTRUCTIONS
9.Total'well depth below land surface: ''Ti.� ✓' (ft.) 24a. For All Wells: Submit this i form within 30 days of completion of well
For multiple wells list all depths ifdii different(example-3@200'and 2«100') construction to the following: '
10.Static water level below top of casing: ist) (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: to Li r (in.) 24b.For Iniection 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: ►zurti 1
(Le.auger,rotary,cable,direct push,etc.) J construction[o the fallowing:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,
I Raleigh,NC 27699-1636
13a.Yield(gpin) 1 Method of test:.7..-I 24c.For Water Supply&Injection 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: AmlA: ount: " ' 5 completion of well construction to the county health department of the county
•where constructed. 1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016
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