GW1--04181_Well Construction - GW1_20230706

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only. ,
1.Well �f)J Contractor6 Innformaatidn:
L �-v�L f:l c(1?'g Qb!',--- /al cl,_ 3 vo..8 kco ., 14.WATER ZONES —
Well Contractor Name FROM TO - DESCRIPTION •
AO7 -II - -3978--2-- a0ft. gsR• id-Aire/A
aCIL 5"1 n � r
NC Well Contractor Certification Number15.OUTER CASING(for multi-cased wells)OR LINER(idap Leable)
0/-QWI t• i /Z 4Y,a r L . FROM TO n. DIAMETER TIUCKNESS 1 MATERIAL
Company Name (J�/ )[J Vu (i
{ ,, 16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: d7''�L S Q FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County,State,Variance etc) .4./ fL /1 4 ' 4 ' silt_ 7u - /1 re,
3.Well Use(check well use): S/ n' .,r_ft. / ' in saj A/0 PV 1—
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MUnicipal/Public 410ft: S� fr. , m. 4240 3ad,t 5s
❑Geothermal(Heating/Cooling Supply) itiResidential Water Supply(single) ft. to.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation • `-t', i f7Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT_
Non-Water Supply Well; i,....i.,:, V a--!--1 0 IL al n I-lo1CP1a P'dk.
❑Momutoring 43❑Recovery ft. ft.
Injection Well: .0 j I it t_Q t-�
ri. n.
❑Aquifer Recharge n,Qegdwater Remediation 19.SAND/GRAVEL PACK(dapph'cable,..-1.. '..•. )
❑Aquifer Storage and kecbvei3!:i,,3.:N ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage .21 H• .5 3 IL •S 4 pia.A-
❑Experimental Technology ❑Subsidence Control it. ft.
OGeothermal(Closed Loop) ❑Tracer , , . , 20.D1ULLING LOG(attach additional sheets if necessary)'
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM ID DFSt RIIPIION(color,hardness mil/mcktppe,grain sat,etc)
,2.-eeeu.)- 1.4-41.,X.c.,,
4.Date Well(s).Completed: /r�9/dI J Well ID#�f-4I dr-s- a Q ft. . l •IL [,L'`,,1 tte-' d ,n
5a:Well Location: c /d'a/4P �t e -O o+�iI 70 11 u;� 41 A e.Q/� (" (�C el_
v YYI v�/I C�r: t?`L 7"0: ft- go:ft- - era
. CJ k--e4e U
Facility/OwarrName Fac11ity1D#(if applicable) 8U ft" 90 1121,44,4
y�tw�/ �t/)L,L/
.. . iL ���
'fci. 7 \r� 7fo C'U 1 " Il .
Physical Address,City,and Zip _.__.
•
9t7ieff a1q O eLI a ,i,1.6"-- 2L REMARKS . _ .
County 'Parcel Identification No.(PIN) • .. .-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(if well field,one lat/(ong is sufficient) _ 22. rtification:, q -`-'--- 39 7 '
,, S t,/g-i 3,3" N 79433' :ZD'' W -(1G K 4.,:„„ a 3
6.Is(aie)the well(s): permanent or, ❑Temporary signature of Certified Well Contractor Dais
By signing this forth,I hereby certifythat thewell(s)was(were)constructed in accordance with
7..Is this a repair to an existing well: ❑Yes ,or MIo I SANCAC 02C.0100.or 15A NCAC 0.2C.0200 Well Construction Standanis and that a copy
If this is a repair,fill out known well construction information and explain the nature ofthe ofthis record has been provided to the well owner-
repair under it21 remarks section or on the back of this form.
21 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 construction info
construction,only 1 GW-1 is needed Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS - .
9.Total well depth below land surface: ).3 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3©200•and 2@100)
10.Static water level below to ;casing' 24a- For All Wells: Original forth to Division of Water Resources (DWR),
P �= A Q ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level II-above casing use"+" ... .. ._
11-Borehole diameter: 9 (m,) 24b.,For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
- l ell-Constr. ' ..
12.Waction'method: : R© I�4' 24c.ForWater Supply and Open-Loop Gcothernial Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc) county environmental health department of the county where installed
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: �j Pit Program,1611-MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amotmt: /p O Z ' : , -
Form GW 1.• North Carolina Department of Environmental Quality-Division of Waterlources Revised 6-6-2018