GW1--03981_Well Construction - GW1_20230612

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1 ,
1.Well Contractor Information:
a er Wizar s W t d 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
Taylor Often 101ft' lb]rt. V2 gQ M
ft. f1.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
4497-C FROM TO DIAMETERM THICKNESS MATERIAL
Company Name 0 it 2�it{S fi. 10tikk in• 9eAl 5kee '
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM�'} TO DIAMETER THICKNESS MATERIALf,
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) V M. M3 IL 9 in- 4O ?VC
3.Well Use(check well use): ft. R'
Water Supply Well: FROMREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
®Agricultural 0Municipal/Public ft ft. in.
II Geothermal(Heating/Cooling Supply) Rtesidential Water Supply(single) ft. ft. in.
a IndustriaUCommercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MAATF>:rsr EMPLACEMENT METHOD&AMOUNT.
Non-Water Supply Well: 0 R. 103 ft. for vkcA� f ou �, 4O�W
I Monitoring DRecovery ft. ft.
Injection Well:
IL ft.
III Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
a Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
®Aquifer Test JStormwater Drainage ft. ft.
II Experimental Technology 0Subsidence Control ft. ft.
jr Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal- (Heating/Cooling Return) FROM TO DESCRIPTION(color,hardness,soil/rock type,gvin size,etc.)
Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: 5 1)-23 Well ID# it. ft.
fL ft. -rA"'a p n
5a Well Location: U__" [..�' ...r • J
-Softies PicA. �`em)S ft. It. JUN
I V
Facility/Owner Name Facility ID#(if applicable) B' ft. J U 1 2 Z 0 23
1 11 ia-n '�• l\. 4 U ft. D. if6vtw, a:. . ;"r...—a..;Linn -
Physical Address,City,and Zip ft. - ft. DWO1SOG
IJv.f�C�Iv\ 21.REMARKS
County/`J Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one!at/long is sufficient) 22.Certification:
3c. tr453 N 78 .gee,37 W c-I�'/
6.Is(are)the well(s)1'Permanent or. DTemporary Signature ofCccl, . ell Con rector Date
By signing this iU I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or DNo with ISA NCAi t2C A100 or I SA NCAC 02C.0200 Well Construction Standards and that a
if this is a repair,fill out known well construct'n 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 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 necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 110 ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2 a 100') construction to the following:
10.Static water level below top of casing: SC (ft.) Division of Water Resources,Information Processing Unit,
If water level Is above casing,use"-r"/. 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: tp l/ 4 (in.) 24b.For Infection 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: ro i v y construction to 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) /Z Method of test: M1�] 24c.For Water Supply&Iniection Wells: In addition to sending the form to
1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: H T f j Amount: Al O 2. 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