GW1--04070_Well Construction - GW1_20230622

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Da 1/1 ci (-Lurkp
Well Contractor Name FROM TO DESCRIPTION
ft. ft. I
-1.3 6 A ft. ft.
NC Well C tractor Certification Number
r °15:OUTER CASING.(for mold-cased wells)OR LINER,(tf ap cable)
�=1'1 BPS j,(�`Ji� ,�r� Yri CD,� Lyle•
FROMft- 1 f, IAME
4 ft• D /TER s f P VG
Company Name
2.Well Construction Permit#: 3 ') 7 16.INNER CASING OR TUBING(geothermal closed-loop) . .
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,variance,etc.) N• ft. in.
3.Well Use(check well use): ft ft in.
17.Water Supply Well: FROM OM TO DIAMETER SLOT SIZETHICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) E(esidential Water Supply(single) ft ft. ' in.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMO
Non-Water Supply Well: v ft. ,:...0 ft• b Qij ' U to 13 b c) S — to 6 arac
Monitoring Recovery ft. ft. 'J J
Injection Well: ft ft.
Aquifer Recharge ®Groundwater Remediation 19:SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0Salinity Barrier FROM TO , MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage ft. ft.
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer .20.DRILLING LOG(attach additional sheets if necessary)`.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,eta)
���� 6 / i' ft- d.,trt;, 6.IAy
4.Date Well(s)Completed: 4 �C. Well ID# //6.ft. 16 cf`' g VA)1l Ten ---�.•-,r ‘, j' rat
5a Well Location: ft. ft. '° ,� L-I y
G11a�/ 2)�Win 1i juN 2 ? n02.3
Facility/Owner Name Facility ID#(if applicable)
f/( ft ft. ef`n i'ri:::xw.t.5 Ur*
/< )1."/� ()`o lei)d. -r lJ r: In(:;: ,Vi1'.`CI���''
Physical Address;ei ,.and Zip ft ft
J 21.REMARKS
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well
field,one lat/long is sufficient) 22.Certification:
Ci ( "/1 g ; lis 01— N r-a Q , /y l I • / l 7 /d w s
6.Is(are)the well(s) ermanent or 0Temporary Signature of Certified Well Contracto 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: DYes or 'ElNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair.fill out known 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 details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS'
f / �
9.Total well 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 different(example-3@200'and 2 )100') construction to the following:
10.Static water level below top of casing: 5 D (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: tU (in.) 24b.For Iniection 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: V 4 I GL.r)/ construction to the following:
(ie.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) -D Method of test: !-j Y' 24c.For Water Supply&Injection Wells: In addition to sending the form to
�jj
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: di D 1"./pi C- Amount: tl L t.ps 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