GW1--03978_Well Construction - GW1_20230612

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WELL CONSTRUCTION RECORD(GW-1). For Internal Use Only: F4
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1.Well Contractor lion: , ' ,
f-1© /r' - Gt • 14 WATER ZONES .' I
WeDCpruxaciorName FROM TO DESCRIPTION
ft ft.
NC Well Contactor Certifi Number 15:UITIER,CASIItG(for m�fi-wed wills)OR LINER fd • )
FROM TO DiAM} THICKNESS MATERIAL
C y, r
ft C ft / in. ,VC '
Co Name / 3 (� / !!
mpany /y6 1c�; ,cn5-1nG_Ox T�rsn .( mer�al .� r)
2.Well Constriction Permit#: FROM I TM DIAMETER/,J/J THICKNESS MATERIAL`�
List all applicable well construction permits(i.e.UIC,County,State.Variance.etc.) v w '� K- / 1n- ,V c
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3.Well Use(check well use): - � m.
Water Supply Well: iTpSCREEN DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMtmi ipal/Public O ft / ft-
FROM in
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Geothermal(Heating/Cooling Supply) idential Water Supply(single) R 7/ fz ro.
Industrial/Commercial OResidemial Water Supply(shared)
t....L-rig2trz TO MATERIAL JJ EMPLACEMENT METHOD AMOUNT
Non-Water Supply Well ��J ft. rel()Chi/A. e'eun !'} /,
DMoaitoring [3Recovery ft ft.
Injection Well:
E)Aquifer Recharge 0 Groundwater Remediation
QAquifer Storage and Recovery 13 Salinity Barrier FROM ;17 QRAVEU'PACK MATERIAL) EMPLACEMENT METHOD
Aquifer Test'
1 �Stormwater Drainage ft
Experimental Technology Subsidence Control ft- ft
Geothermal(Closed Loop) Tracer :'29:DRII.LING:fAG_(attach additional sseeir:ifneaissarg)
ft.Geodte tmal(Heating/Cooling R ) Other(explain under#21 Remarks) FROM TO ft. DESCRn'TSON(mbr,tags,sm7hvck type,gains,ecc)
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4.Date Well(s)Completed:- d f5 � 3 Well ID# 5 ft. 39° ft. ��‹_
Sa.,Well Location: ft.
/ (4LI �i s,'l,`0 iv ft ft r1t....�� >f�711
Facility/Owner Name Facility liDi(if appl e) l 'a .1" � I' l
-S / 6 (/04 f ice^ e' ft ft. JUN 1 9 7073
: Physical ,City,and Zip ft ft
1—. . 2LREMARrfS In.Rr'firlrfatiO;1 t'fC.:::NVer-og lira
County Parcel Identification No.(PIN) DW13
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W A( 'CX-7/ii J
6.Is(are)the well(s) Permanent or jTemporaly Signature of Certified Well Contractor Date
� By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or o with 1SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out,brawn well construction information and explain the nature of the Copy of this record has been provided to the well owner.
repair render 111 remarks section atom the back 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 necfsary.
drilled:
Q SUBMITTAL INSTRUCTIONS
0) 39.Total weQ depth below land surface: (ft.) 24a For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if ele-memt(example_3(a 200'mid 2@,1001 construction to the following: '
10.Static water level below top of casing: / S' (ft-) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,sae"+" 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 fl fa/-N, above,also submit one copy of this form within 30 days of completion of well
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(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 7 Method of test . N 24c. For Water Snooty&Injection Wells: In addition to sending the form to
/ It the address(es) above, also submit one copy of this form Within 30 days of
13b.Disinfection type: // / Amount Li Z completion.of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016