GW1--06670_Well Construction - GW1_20241108

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Vowi I Vow 14:WATER ZONES'' I
Well Contractor Name
4Z'�� FROM + TO DESCRIPTION
fL i0 i ft. 50iprm
0 ✓ 0 ft. ft. l
NC Well ContractorCertifrcation Number
(/1(/� (1��1�/�� c1l�11� / 1S:.OUTER CASING(furl►idt4n-cas�etd�lveils).OR LINER(Map &able):.
2 e ls/Y 9! s 2,u'�t :I I p�, (AT �io • FR M f i 2Ik1 ft. D[f�,�'T R in. THICKNESS MATERIAL
Company Name 1 9,.,i�j (�}
AS.-NSW
16.INNEk-CASIN'G OR TU,BI[1'G(geothertnal:closcd.1oop). _ . .
S 2.Well Construction Permit#: �, FROM TO DIAMETER THICKNESS MATERIAL _
List all applicable well construction permits(i.e.UIC,County;State,Variance,etc.) ft. ft. • 1 in.
i
3.Well Use(check well use): it ft. ; in.
,. :.
Water Supply Well: .17:SCREEN ;
Agricultural FROM . TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Municipal/Public ft. ft. in. ,
Geothermal(Heating/Cooling Supply) ki Residential Water Supply(single) ft. ft. in.
Industrial/Commercial °Residential Water Supply(shared) 1
Ilk GROUT'
Irrigation FROM TO fATERIAL�•_ EMPLACEMENT METHOD&AMOUNT
V L
Non-Water Supply Well: - ft.: '�r� ft. l f
Monitoring °Recovery ft. � ft.
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
Aquifer Storage and Recovery Salini Barrier 1;9.SAND/GRAVELPACIC( apidicatile)
ty MATERIAL TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG::(attach:additionalsheets teaecessaty):..- -. .
Geothermal(Heating/Cooling Return). FROM ' TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
g/ gnOther(explain under#21 Remarks) i{) R - I 30 ft. ti
4.Date Well(s)Completed:10)11It(4 Well ID# left• ( 2-,f-ft, ii
5a.Well Lo'cation: ft. ft.
ID'ca
Facility/Owner Name /� Facility ID#(if applicable) • ft.' ft.
\eeLP 7 iu ' . aUi A Nigtp ft. ft. NOV 0 8 �UL4
Physical Address,City,and Zip ft• ft. it !TIN
PaltUCal jo(-k 4S"o f p 21.:12EL1 ARKS- -,
County Parcel Identification No.'(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one lat/long is sufficient) f n 22.Certification
2
fOff�l q
"7„,,.....A-------,
6.Is(are)the well(s) Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certih•that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or 4No with 15A 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 and explain the nature of the copy((this record has been provided to the well owner.
repair under#21 remarks section or of 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: SUBMITTAL INSTRUCTIONS I'
9.Total well depth below land surface: 0 25 • (ft.) 24a• For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths fd(erent(example-3@200'and 2@100') construction:to the following:
1
10.Static water level below top of casing: (ft.) Division of Water Resou Ices,Information.ProcessIng Unit,
0 waver lent'l is above Casilll.use"' 4 - 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: (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: gpjrnild constructionto 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
13a.Yield(gpm) Method of test: /y�.' � 24c.For Water Supply&Injection Wells: In addition to sending the form to
I/ nn the addresses) above, also submit one copy of this form within 30 days of
'73b.Disinfection type: Amount: 1.��� ! l omptettan nt-welt construction ua the county health department et the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources ' Revised 2-22-2016