GW1--04050_Well Construction - GW1_20230622

WELL CONSTRUCTION RECORD(GW-1) • For Internal Use Only:
1.Well Contractor Information: r
Ow}� �..1.eur eJ
Well �atractorName FROM TO DESCRIPTION
3 S23 `'fl • .5. ft. n
NC Well Contractor Certification Number 15.OITi'ERCASING(kik nimbi-eased wells)OR LINER'tlf ii "ble)'
/ �'/.q� De",� FROM TO DIAMETER THICKNESS MATERIAL'
�!� R ft. hi.
Company Name
16.INNERS:ASINGORTUBING(peothermddaaldoop) `_ " 4:::... ..
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance.etc.) O ft. Sv,.)-fL 2"
in t A•, Pvt.,7V /.
3.Well Use(check well use): fL $' ft. r t in. 4
Water Supply Well: • 17.St3REEN ..,..,:..,..; �•.. :- a i
FROM TO ..z DIAMETER SLOT SIZE.., THICKNESS MATERIAL '
Agricultural • DMunicipal/Public 0r314 ri,, n. l..to sokas yd Arc:- ._.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single)8
fit. n.
Industrial/Commercial [Residential Water Supply(shared) jta GROi9T. 7: •--. --,*. . :=.
( •
"Ilrigation * �'I',1+�.' FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non- seer Suppt�welte ` !-o -p-n.- n_
. �►c,•�- Piz z 1:
onito '1•r- r DRecovery ft. ft. •
Injection Wgllt. c 9.4 '63r3 _
:t infer Rechar `
Aq gs�`t�`1oundwaterRemediation 19SSPiD/GRAVEi:RACKtit4ppiicable): _
Aquifer Storage and Recove F- Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
20.DRILLING LOG -
Aquifer Tes�t�,, . DStormwater Drainage fat' 70,ee ft. 7 5#,,,`t
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer -- (attach addttional.ebeete if neeement '.=-i•.: ... .: ::
FROM TO DESCRIPTION(color,
Geothermal(Heating/Cooling Retum) °Other(explain under#21 Remarks) Wines,solllrocic rvae gam arm etc.)
v ft. .1. ft- 4 rowQ•Z
4.Date Well(s)Completed: .S 30 -23 Well ID# MIN) ) 1, It. ').r ft. S i 14 S A 0 et Qe.t _18rr+44.0 ei car
5a.Well Location: 1)'S ft. 13.3 ft. 5;bii-5;14 / Arpt+rvl CL�...
•
pact; A Ala 14-ictz- Labs N�g -? )3.,ft- g), --ft�,�7rf l� yell., ti .
Facility/Owner Name Facility ID#(if applicable) S'"1,t;ft. 9g, ) ft. p .) 7
3 2 LS PC ' 251 1\1 nn j F i•J 0,1. .. gait. e2,9- ' M12,Oar el P1+0,- 6N e,SJ
Physical Address,City,and Zip ft. n. .
I�fOCp 1+9 Jae 2L'RE111tsRKS':a.•,,,:.: . . • . ......• ...
County . Parcel Identification No.(PIN) •
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1st/long is sufficient) 22.Certification:
3s,L 4I599L N - el . S'ci L 3 i (p `i'` '�� (a - I -2
Temporary ugna fCertifled Well Contractor Date
�6.Is(are)the well(s)9<rmanent or � By ' ing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or o wi I SANCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
.f this.is a repair,fill out blown 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 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: SUBMI'ITAL INSTRUCTIONS .
9.Total well depth below land surface: (1) 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: 5704 r (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
,
11.Borehole diameter: g r (in.) 24b.For Inlection 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: A u4 a/'
(i.e.auger,rotary,cable,direct push,etc.) J construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) _ Method of test: 24c.For Water Snooty&Inlection 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: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016