GW1--06553_Well Construction - GW1_20241101

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
V t n) V'`/�W 1° i4.:1VATERZONES
Well Contractorr� + Name FROM TO DESCRIPTION
L. 1 6O ft. 305
� ft. lt11
fL ft.
NC Well Contractor Certification Number 15.OU.TEft"GASING(roc nultt-ekied wells)a]R LINERr(ifap'17AL
linable)
j �j,��y,9�/( �� I FROMTODIAII7ETER TIIICKNE5S AR
erpw
7i'tf'y ,^„ 1 vial
iw. �j ft. ft. I E i in.C an Name ,
Company �.�J�n�r� 36 INNER'CASING:OR,TTJBIN(fj eothetmaliclosed loop}
2.Well Construction Permit#:Waling g -(--)r 32_ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC County,State,Variance,etc.) ft. ft. in..
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 1'I'SCREEN . .. tT _ . , .
pp y FROM TO DIAMETER• SLOT SiZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. ini
Geothermal(Heating/Cooling Supply) MResidential Water Supply(single) fL ft. in.
industrial/Commercial 0 Residential Water Supply(shared)
1S.GROUT ,; , .,.. F;,= ,:.:
Irrigation FROM . TO MA��TEERRI,A�L�; EMPLACEMENT•h orticiII'&AMOUNT.
Non-Water Supply Well: a ft. 2Iry ft. ji /'11 f(.Y)lfa, , ,_ Ft. • .
Monitoring DRccovcry ft. ft.
Injection Well: ft.. ft. NOV �(��1-
Aquifer Recharge DGroundwater Remediation it R
„19l;SANDIGRAVEL'PACK(If applicable) ,:.; . ,,. -':� {sn'
Aquifer Storage and Recovery (Salinity Barrier FROM TO MATERIAL EMPLACEMENT..MF.TJiOD
Aquifer Test DStonnwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20 3R.111'LING;T OG(attach'additttinul sheeti3f iiicessa':
rya _
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) ft. ft. /1 f
4.Date Well(s)Completed: g)7 24 LII Well lD# (p0 ft. LOS ft. \(-�//y- 1 ei.
5a.Well Location: ii11�� ft rr•�t✓✓. ft ei ' {l���7� t�C1
•—I� k'ci. �n 1: Yll�-{-ICIP�,,.� ft. ft. U
Facility/OtUicrName Facility ID#(if applicable) ft. ft.
ft. ft.
Physical Addres,City,and Zip ft. ft.
21:REDIA3RKS .:....
Coto
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.Certitic�ti n:
C.5.00I(p N - �2.7io W `
6.Is(are)the wells) Permanent or [jTemporary Signature-of Certified ell Contra r Date
By signing this form,I hereby cert( 'that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: )Yes or ANo 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#121 remarks section or on the hack 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: ISUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: LI D5 (ft) 24a. For All Wells: Submit this fonn 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: WO 20 J (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,rruse''+t" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: W j1T (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
I a-'t above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 111"��wvv A/Y ei construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLYn WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ` Method of test: / 0tit,V5 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also subniit:one copy of this form within 30 days of
13b.Disinfection type: 41114 Amount: -ry 14'ink)
CS completion of well construction MI 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