_Well Construction - GW1_20230320 (87)

ee -•vas vv1\U11\V1,11V1' iNua..vlIUr For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
_- /� 14.WATER ZONES-. r .'
9�e1 vrJ Y) 25e( ll J.(e I/�rex /4 C/7 icW- FROM TO DESCRIPTION
Well Contractor Name - ft. It. &,5- /lip, �c2 GI/ [ ? ��'
02 O 36 it. it l �' J
NC Well Contractor Certification Number • 15 OUTER CASING,(for multi-cased'Wells)OR LINER(if ap licable)'-.:.'
FROM TO DIAMETER THICKNESS MATERIAL
99.L. /»wd/, s We (I /✓r;air,, =ir/c. .71
I ft ..5 r3 n• (i7%. in. ,d_ Pve
Company Name 16 INNER CASING OR TUBING(geothermal closed=loop)"' ':= .:•;.:`::`'.::
2.Well Construction Permit#: . �,•` - G. 4 •
FROM ft TO ft DIAMETER in.
THICKNESS MATERIAL
List all applicable well construction permits(i.e.Countyt State,Variance,etc.) ft ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM .TO DIAMETER SLOT SiZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) fdential Water Supply(single) ft. in.
18.GROUT ..:... .
❑Industrial/Commercial ❑Residential Water Supply(shared) FROM .TO
MATERIAL EMPLACEMENT,METHOD&AMOUNT
❑In-Wale 0 ft' a 0 ft ✓J f'Dyli� per)ct/E.Cr
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL-PACK(if applicable) • -. -.-
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery OSalinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING L'OG(a.ttach ad'ditionaf sheets:if necessary)';=:` '
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION colon hardness,sail/rock ,•
( type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) O ft a v ft. Red e e,y
4.Date Well(s)Completed: - .3 u.2D y 0 ft J1 si•�n' /i3� .sr.
5.Well Location: J It £3 ft /3eue
vita iiii-C L CtD 53 ft 3o rt �13 e Grp-
Facility/Owner Name Facility ID#(if applicable) I:::
- r, r y ,-7.-- z
.. :.s t� �..- ,,..,8
f zit L' i ih' e r'C_re,5 17/1/J•Ci3v10b14r �ft ft. MAR
Physical Address,City,and Zip .•. -;: .MAR.9 e-2Q23 .:.. , .
���.� 21.REMARKS... .. -
Ini.)ct sti^n ?rac:3a,;'31 in4
County Parcel Identification No.(PIN) :a'Cir r•'3O>r
•
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification:
(if well field,one lat/long is sufficient)
35 . 3 I S/2 N 669 41570253 W 9f r 6
Signature of Certified Well Contractor Date
6.Is(are)the well(s): CR'ifermanent or ❑Temporary By signing this form,1 hereby certf&that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or l +td copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this firm. 23.Site diagram or additional well details:
J You may use the back of this page to provide additional well site details or well
' 8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: 3 e9 0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'andL22Q100') construction to the following:
10.Static water level below top of casing: 3✓ (ft.) Division of Water Quality,Information Processing Unit,
'' limner level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
� /�
11.Borehole diameter: (in.) 24b.For r Injection Wells: In addition to sending the form to the address in 24a
/� • above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: /t-D far , construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
nn 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) 3o Method of test: !7/ y' the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 1 l-� Amount: �Jt`n. , completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Ian.2013