GW1-2023-00986_Well Construction - GW1_20230118

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Informat�'on:
L 14.'WATER ZONES
FROM I TO DESCRIPTION
Well Contractor Name U ft. fL
g51,5 mod- . ft. &
NC Well Contractor Certification Number i 15.OUTRR.CA8IffG'.fhr,j u ti:eaeed wells UR1 INER'ita licable
FROM TO DIAMETER TffiCEOYESS MATERIAL
w d Pu I ft i TO ft. •125 t° s ,21 ��
Company a �j /� 16.'IbMR CASING OR,T.UBING• 'edthermril'closed-too
2.Well Construction Permit#: /`�7 +S FROM I TO DL(METER I THICKNESS I MATERwL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
ft. �
3.Well Use(check well use): ft.
17.SCREEN.
Water Supply Well: FROM TO DIAMETER SLOTSUM THICKNESS MATERIAL
Agricultural [DMunicipalftblic ft. ft. In.
:)Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft, ft In.
IndustriaUCommercial Residential Water Supply(shared) 1s.OROUT.
Irrigation E19SAR451C
TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: n ft. v�
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation' RAVEL PACK, a licable.
Aquifer Storage and Recovery; _ Salinity Barrier FROM To MATERLtL EMPLACEMENT METHOD
Aquifer Test .;.,`; [3Stormwater Drainage ft ft
Experimental Technology �.".' [3Subsidence Control ft. tL
Geothermal(Closed Loop) OTracer 20.'DRILLING LOG.attach additibnslsheets:ifoccessa
FROM TO DESCRIPTION color hardness soWrock s ele
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) 0 & Igo ft.
4.Date Weil(s)Completed: /L-2op-� Well ID# t It -305 fr r
M ft.
5a.Well Location: -
ft. ft. �,��1 "e
XtlIVI MU!.vl�eli
Facility/Owner Name Facility ID#(ifappficablo) ft ft.
5�3 /1�lccuy� y'�J( Rd ft. JAN ZON
fL
Ph y cal Address,City,and Zip ft. ,1a
21.REMARKS
�r
lag�-�• -
County Parcel Identification No.(PIN) —
5b.Latitude and longitude in degrees/minutes/seconoor decimal degrees:
(if weu field,one lat/long is sufficient) 22.Certification:
35 ,376T9 N —31,.319111 w � 1-�j 13
6.Is(are)the well(s) Permanent or [3Temporary
Signature of Certified Well Contractor Date
BY signing this form,/hereby terrify that the well(j)runs(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or ONO with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,Jill 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 ojthis form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Wells having the same You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed.'Indicate TOTAL NUMBER of wells
drilled: - 2/� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 303 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths lfdiTerent(exatpple-3(�00"and 2(a3100� construction to the following:
10,Static water level below top of casing:" co (ft.) Division of Water Resources,Information Processing Unit,
Ijwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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.. flo4lw I construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resource's,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) <—"' Method of test: 41"_ 24c.For Water Supply&Injection Wells: In addition to sending the form to
�
�J the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:(�1�r`lr br'`!t 2 Amount: <Gr' S completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofF.nvironmeatal Quality-Division of Water Resources
Revised 2-22-2016