GW1--04732_Well Construction - GW1_20230724

VV JCJL,Il., +l.AJ1'tl y 1 JLCUlU S1.1_Wilt IRMA-.Vre.ILY For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
��re,/ t 1R WATER7,ONE& .
Te
c( 1GC eft ,I� Y/Gc/1 P�'� C FFROM TO DESCRIPTION
Well Contractor Nam ft. ft. ( 5/ '� %
(L?
q0 ft. ft.. p(
NC Well Contractor Certification Number .15.OUTER CASING(for multi-cased wells)OR LINER(if applicable) ''
/y� / / p� / FROM TO DIAMETER THICKNESS MATERIAL
V(, /i/G.// 5 ai el/ Uif1 r%7C`' �2/C / ft. / 93ft. 6f/�in. r/a5 l Ps/c
Company Name `�' 16.INNER CASING OR TUBING(geothermal closed-loop) .. .
v FROM TO DIAMETER THICKNESS MATERIAL
i 2.Well Construction Permit#: . D O/3_.5 ti 3 ft. ft. in.
List all applicable well construction permits(i.e.County.State,Variance.etc.) ft. ft in.
3.Well Use(check well use): 17.SCREEN -
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agicultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) dential Water Supply(single)
ft. ft. in.
•
❑Industrial/Commercial ❑Residential Water Supply(shared) is.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation V,1 ft ft. G j pn n r+„I/srp Gc ce S
Non-Water Supply Well: O-
ft. ft.
❑Mon itoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK(if applicable) . ' .
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery 0 Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLINGLOG(attach-additional sheets if necessary)' •
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,sell/rock type,grain size,etc.) •
❑Geothermal(Heating/Cooling/Return) ❑Other(explain under#21 Remarks) 0 ft• a 0 ft. /`P d C f�y
4.Date Well(s)Completed: t� a3
tr. Coo ft. p����O e ei 4' u�
C�0 ft- /c�3 ft. ¢ Gruve l / 6 ,S`
5.Well Location: .�
�`� �, /03 ft. 3 eat. G.
(-4 -K ' e% r -e_ 1D N4 ft. ft.
Facility/Owner Ndle Facility ID#(if applicable) ft. ft. "i
�Sya .5c1.n5et i d L.. ,A ��� -a-
ft. ft. "• ���6==.°
Physical Address,City,and Zip 21.REMARKS " . +r i 6A il..7 i 1/j
°cV h rshu.rr 63'-®5LI- ;5 . , ,.Jt_ ea . -
County J Parcel Identification No.(PIN) InfOriiir.f1 i�rc•c:s 'r %"''
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: J
22.Certification:
(if well field,one lat/long is sufficient)
350 31 0 5 7 N a o , `d 7 7 7 '? W -12../'-6.-L_ 6 -0 023
a r fCe ed Well Contractor Date
6.Is(are)the well(s): ft'1'' manent or ❑Temporary By signing this firm.1 hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or I11LVo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 1121 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: / construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the sane construction,you can
submit one form. 24.Submittal Instructions:
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-3Q200'and 2Q100') construction to the following:
10.Static water level below top of casing: 3 5 (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing.use +" 1617 Mail Service Center,Raleigh,NC 27699-1617
JJ
11.Borehole diameter: IC/ �Sy (in.) 24b. For infection Wells: in addition to sending the form to the address in 24a
/� • above, also submit a copy of this form within 30 days of completion of well
/)
12.Well construction method: e/ /G r (/ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) /
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
AT r 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) /0 Method of test:
the address(es) above, also submit one copy of this form within 30 days of
H �hi completion of well construction to the county health department of the county
13b.Disinfection type: Amount: 3 Pi I'1 where constructed.
Fonn GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013