GW1--03758_Well Construction - GW1_20230602

WELL CONSTRUCTION RECORD (GW-1) Fer Internal Use Only
1.Well Contractor Information:
Jason i%!Z'
Well Contractor Name
Q� FROM TO A DESCRIPTION
ft. t� © ft. 0 ' M
ft. ft.
NC Well Contractor Certification Number 15.UUTER'CASING [or'"_multi-cased wells'OR LINER if "8enble
GG a p� e I �� / �,- FROM TO DIAMETER THICKNESS MATERIAL'
1 I J W ft. 7 3.ft. in. r.j+�$' 6 v G bl '
Company Name J INNER'CASING.OR'T,UI3ING
p cottie`rmuhelosed too
2.Well Construction Permit#: I 0 q"/�1 FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County.Stale, Variance,etc.) ft. ft. in.
3.Well Use(check well use): tt. ft. in.
--
Water Supply Well: FROM TO DIAMETER SLOT SiZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) ffiRcsidcntial Water Supply(single) it. ft. tn.
Industrial/Commercial DResidential Water Supply(shared) 18,GROUT. :` .z.., _
Irri ation FROM TO MATERIAL EMPLACEMENT-METHOD&AMOUNT
Non-Water Supply Well: 0It. It. w Of Y-4 V fty
Monitoring ORecovery ft. ft.
Injection Well: I
ft. ft.
Aquifer Recharge OGroundwater Remediation
,.19.'SANDIGRAVEL'PAGK`if n`_tieitble -`-
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E)Stonnwater Drainage ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer :2orDRII IING`LQG attack'nddltToiiatstieet3'ifnecessa" := �, ._'
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DFSCRIPTTON color hardness solOrock e- rain si etc.
Aft. n ft, . _ 0 1_c.
4.Date Well(s)Completed: Well ID#
l0 dt. p & a, e rd c
ft. ft,
�IL�Zrs / C F �
Fncilihdtiurnrr Nur2.r c.;.:ra_ma rpr___r;r_�i_. fL ft_-
G 3
9 5 t� � kwi 701 1 Fv r D�Ks ft. ft. :._r InR
d rn ft.
Phvsical A,I,Sregs-rlhr........... _•:ten i�T:
- r t•��
u 3faRE1VIARKS._: _ v �^
County Parcel Identification No.(PTN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) 22.Certification:
N
[.- yetq.nl H.,. W Q'nnatn n rinftinnd xvn!i rnn .. .
By signing this form,I hereby certify that the well(v)was(were)eonsiructed in accordance
7.Is this a repair to an existing well: []Yes or E]No with 15A NCAC 01C.0100 or 15A NCAC 01C,0100 Well Construction Standards and that a
"this is a repair,fill out known well construction information and emplain the nature of the copy of this record has been provided to ire we17 owner.
repair under#11 remarks section or on the back of t is 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: ' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:_.__ �l� (ft-) .• _
._...... +. ....«.«.».. �.w uuu e�yt vv7 - .._.
- A construction to the following:
10.Static water level below top of casing; �� (ft.) Division of Water Resources,Information Processing Unit,
If i ater level is above casing,use' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: r �� I �V f^ above, also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct to the following:
push,etc.) g
FOR W Division of Water Resources,Underground Injection Control Program,
ATE R SiTPPi V WELL.
13a.Yield(gpm) Q Method of test: 1 iD W 24c.For Water SUPPIV&Iniection Wells: In addition to sending the form to
the address(es) above, also submit' one copy of this form within 30 days of
13b.Disinfection type: Amount: l b completion of well construction to 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