GW1--04127_Well Construction - GW1_20230623

Punt Form
/7 WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor I'nfolimatioi:
i
i-'4.t/! (.GL/'n.o :14.WATER ZONES. _
Well Contractor Name d FROM TO DESCRIPTION
ft ft. 1
NC Well Conyactor Certification Number
(�� �/ ) p /•? IAA 15.OU1'ER.CASING(for.mold-cased wells)OR.LINER'(if iip caybble))
Z b 1 5 t/V e-.l ) Pa l.A, !1'1 C, FROM
� ft.
(T, r 5�Il rrZ-� I" Y MATERIALDIAMETER THICKNESS
Company Name 16.INNER CASING ORTUBING(geothermal'closed-loop):. .-
2.Well Construction Permit#: .5 1112 - .6 i� 77 FROM - TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.(IIC,County,State,Variance,etc.) ft ft• in.
3.Well Use(check well use): ft ft m
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DM cipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft in.
Industrial/Commercial Residential Water Supply(shared)
Irrigation' FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft. ft. ��f1 �%tJ C: �7 134- "�D L1 Y P,
Monitoring DRecovery f. ft J
Injection Well:
ft ft
Aquifer Recharge OGroundwater Remediation 0
19.SAND/GRAVEL PACK(if applicable) • - _ ..
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer `20.DRILLING LOG(ankh addlttonil sheets if necessary).
FROM TO DESCRIPTION(color,hardness,sollirock type,grain slat,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) , �'
/ ) D tt Pri f' j j it Jt c-i y
4.Date Well(s)Completed: 4-cJ f Well ID# 1 RI g'r--ft' t
ft ft
5a.W�sII Location
vit-r 1 t i- 160.11�5 i A.�?^ Fr-F.
Y ft ft. v L.Le L A V L.L.
Facility/Owner Name w1 Facility ID,N(ifapplicable)
1461 Fr red I v 14)'r RA, . ft. ft JUN 2 2023
Physical Address,City,and Zip . ft ft
L R tA'') r.)-.Yel .21.REMARKS.... Infraira,i:.il i'rc'-We:)itt„Fr:
County Parcel Identification No.(PIN)
•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long ist sufficient) _. 22.Certification:
-5s , .�v `3 / N � 51: F I bJ 5 W y
6.Is(are)the wells) ' Permanent or Temporary 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: QYes or R1No with 1SA NCAC 02C.0100 or ISA 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.
filled: SUBMITTAL INSTRUCTIONS
1 j,
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 L) (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: 6 (in.) 24b.For Injection 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: I re-( ji 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
e 1
13a.Yield(gpm) c 0 Method of test: .4 11" 24c.For Water Supply&Iniection 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: 4 /O r] )'\E, Amount: ,L t'.LLID 6 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