GW1--04734_Well Construction - GW1_20230724

WELL CONSTRUCTION RECORD . For Internal Use ONLY:
This form can be used for single or multiple wells
I
1.Well Contractor Information: -
t r I4r'WATER'7.ONES•;:.. c:.. _ :..1:'i s
• _-.N e FFre y & €r //3i'/„ ,n /�!//�r/C o -FROM TO DESCRIPTION
'ell Contmetor Name ft. ft. I'& �9 O /,•Oc 1�0 / C, 5
--- L.io oL ft. ft. I!<T59 o�5/ o v
NC Well Contractor Certification Number - .I5 OUTER CASING(fo multi-cased;wells)OR'LINER cif ap'licabte):'- -
� � FROM TO DIAMETER THICKNESS MATERIAL
/ Mt,//Its wG
e!/ 9/.14 / . tic let ft. 1 `) ft. /fin. , /2 5 . f c
' .
Company Name 16:INNER'CASIITGG OR TUBING(geothermal closed-loop):.':
/� FROM TO DIAMETER THICKNESS MATERIAL
Z.Well Construction Permit#: • /D //O d (./S ft. It. in.
List all applicable well construction permits(Le.County.State,Variance,etc.) ft ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑MunicipallPublic
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft. in-
• ❑Industrial/Commercial ❑Residential Water Supply(shared) •18:GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation �] P
Non-Water Supply Well: ft. ft.A D f e')1( fl c& f D e( r
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL:PACK(if applicable) -. .
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fL ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology 0 Subsidence Control -
20:DRILLING'LOG(attach additional sheets:if necessary)'-. =;:
❑Geothermal(Closed Loop) ❑Tracer FROM i TO I DESCRIPTION(color,hardness,soilfrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0fL a o ft e`-IC (.-y
4.Date Well(s)Completed: 7'— C� c2 3 `. 0 1L 413
ft. LGc a 6...-.s�C.�
y 3 ft. Ga5dt- r. Ll.f•e x.,.:
f -',Well Location: • -
in mu /V y, ft. ft
'-'` -` /1'?•e.A/6 /I I u ft. ft.
Facility/Owner Name Facility ID#(if applicable) �o f pm
fft. ft.
R_cta d �
k,o 3 ferakus'6n Rd. , ft. ft.' a A ?n2�
Physical Address,City,and Zip JUL.
21.12EMARKS: ..
•
/7)eck Olen 1 is r,- . t4.fe;rsvt_'O:iretl prf c•sori ir4 Unit
County Parcel Identification No.(PIN) CWCUSOG
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
;(if well field,one lat/long is sufficient)
350a 117 , N So; S '7939 w h.,. 7-6 -a3
� � a Ce Well Contractor Date
6.Is(are)the well(s): le3Permanent or ❑Temporary • By signing this form.i hereby certify that the well(s)was(were)constructed in accordance
�_� with 1SA 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 leivo 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#21 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 same construction,you can
submit one form. ^^�� n 24.Submittal Instructions:
9.Total•well depth below land surface: p( 50 (ft.) 24a. For MI 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: 3 S (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing.use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (o/$ (in.) 24b.For Injection 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
-- /�,:2.Well construction method: /I(9 /-t y construction to the following:
t e.auger,rotary,cable,direct push,etc.)
2 Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
24c.For Water Supply&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) LI ©1 ,�/ Method of test: 1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type 1T !/ Amount: 3 fir) / s' completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013