GW1--04727_Well Construction - GW1_20230724

Ir. G Pr iFtCorin' f
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1. ell Contractor Information:
cirrc! * t�'ilc1 14:.WATER*ZONESI. t,..,' '..i97,1 �.. _it_t#,t_6 x$'_!c '�... *
Wen Contractor Name FROM TO DESCRIPTION
ft
'l5 Y5A ft. ft. II I
aN Well Contractor Certification Number s O,D r• n
n /� ,15TERGASIPIGt(for.;mNt[-caaedwelt9)�UR�LINER�,(if:ap llc`ahle)ev
/4 �e1 Cold_/ rJu /(�0. FROM TO DIAMETER THICKNESS TERIAL
I p I h. 7 o ft. G /25! SDr12,l Pvc •
Company Iffame /
/
0 1/� 16 INNER�CASING,ORTiIBINGI(geuthermalrcldsed=loop);: ., ,.,i '
2.Well Construction Permit#: FROM < TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) It. ft. In.
3.Well Use(check well use): ft ft. in.
1 !17 SCREEN!-.,,t ra..x. _iae5.tt ,Uft.�wr, z...:.. �. .. ._ :al _`° 6.£ ;'i�i rt
Water.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agrcultura Su PplY Well: DMunicipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. In:
Industrial/Commercial DResidential Water Supply(shared) •
A GROUT.. iZa.' ku - ., •�_. :, ..rt' ,r . 'i
Irrigation FROM TO jI�ATERIAL EMPLACEEUPIT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 7.0 ft' WnI fe 10 1 S
Monitoring Recovery ft. ft. QQ
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
4f,19.iSAND/GRAVEL,PACK'(IftappUcable) ` .,:o _. _.F:t.r.t, = M✓r, 4.. i
Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ' `., ['Stormwater Drainage• ft. ft.
Experimental Technology. :;\.' DSubsidence Control ft. ft.
VA(111DRILLING<L'OG.(attichliddltfoloaffehect�.Ifiieeewary))4w •«r>v =3
Geothermal(Closed Loop) QTracer
Geothermal(Heating/Coolti Q ng Return) Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rock type,grain sire,etc.)
/�- p ft. 7nft. Clay 1
4.Date Well(s)Completed: 1r/ 23 Well ID# 7 1 ft. 305 ft. &r ,1 7 t
5a.a.Well Location: ft, ft
(3o Ce LG d Wfyi ft. ft. �_ :s �" F g�_�F'°r1
Fa lit/Owner Name Facility ID#(if applicable) H' ft.
f'1cicoon Rci .- Afclq(, WctIIC/6y eulnnyl1�/rf ft. ft. JUL d 4 CO23
Physical Address,City,and Z V R' ft ` e,.�Arset+ri Pren34aifi I Uc
/l/IcDOWei!j '2vREMARK5 ,gilw =ri m,mr"', _.,:59'4 1ismo..t .N n,-kf,,_,5 ,i
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:
-
35 .7451.5 N -.5/.Cl e 6 20 W i1, ka . 7-16;Z-
the ells Permanent or Tem ora Signature of Certified Well Contractor Date
6.Is(are) w () D p ry
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: ['Yes or 1111No -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: 30 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-3Q200'and 2 aC3100) construction to the following:
10.Static water level below top of casing: : 6 d (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,Ilse"+" 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: AO#Cfy 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 Mall Service Center,Raleigh,NC 27699-1636
A.
13a.Yield(gpm) Y Method of test:/'*s e 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 type:Cl/iierii7 Amount:a .Coy S. 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