GW1--04071_Well Construction - GW1_20230622

l' Print Form r
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1 11 Contractor Information:
6
J _I 4 14 WATER ZONES. :
FROM TO DESCRIPTION
Well Contractor Name
ft ft.
NC Well Contractor Certification Number �{/� Q� 15.OUTER.CASING;(for muulltl-cased(�wells).OR LINER((if tip usaae/bbl]e),) .'- -
CCAMDFRO
,s Well GI ! j1 1/11� l t,, fM ft 60 ft 1f:I J b. S� �C.1 / • I'°
Company Noise r� J 1 ' .-16.INNER:CAS NGOR TUBING'taeothermsLdosedaeop) • ,,
2.Well Construction Permit#: i ,7 1 / 1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft R' m'
3.Well Use(check well use): it ill.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipallPublic ft ft in.
Geothermal(Heating/Cooling Supply) QResidential Water Supply(single) ft ft in.
Industrial/Commercial Residential Water Supply(shared) 18rGROUT ;:..
Irrigation FROM TO,/ ry EMP/L�AC METHOD&AMOUNT!,
Non-Water Supply Well: 0 f. 10 ft ;7Ch1 fee 1 v IS�7C/Y�5
Monitoring Recovery ft. ft. t/
Injection Well: ft. ft
Aquifer Recharge ®Groundwater Remediation 4
19:SAND/GRAVEL PACK(if applicable): ""
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO .MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage fr' ft'
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20:DRILLING additional abide tf necessary) - .
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiUroek type Brain sir etc.)
0 60 .Icty111-7 l
4.Date Well(s)Completed:Niti//r2.3 Well ID# �i 1 rt 1 ft &v'st)1 1 r
5a.Well Location: ft ft. • r'7.7'' :.Ir'"- ,r
ft. ft E 4 ® j 0......11 AS' 1:....-
Facility/Owner Name Facility ID#k,(if applicable)
1056 toiiA, s I'cii is j't . ft. it ?iu:.,..-gat a
�? f. ft 1ntE:•7 LI
Ph real Address,City, d Zip EV f Pr FIOG
C4 S 1 o 7l 21 REMARKS . _
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: • e
3S. Y? f:) ,. g1 . z5fp� , -- ,: - . _,,
N �i' 4.3 -G'✓1/l.G 1"`G -eU�. .- e —f
6.Is(are)the wells) Permanent or Temporary Signature of Certified Well Contractor U 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: QYes orb No 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,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: 12,5 (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 20�00''and 2@100') construction to the following:
10.Static water level below top of casing: -10 (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: (2 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
1 above,also submit one copy of tliis form within 30 days of completion of well
12.Well construction method: �() 1 CI r 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) C 0 //��Method of test: -A 'i r 24c.For Water Supply&Injection 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 type011 GYj n t Amount: cup 5 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