GW1--04774_Well Construction - GW1_20230724

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information •
1U K 1-, V`V 1/• lit r• 14.WATER ZONES-. .
C Ls FROM TO DESCRIPTION
Well Contractor Name I 0'5-ft. qO ft.
20'3 G .s'. 2 Sit' 7 ft'
NC Well Contractor Certification Number ` 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable) . .
FROCKNES
�� 1`�O 1 r 1 1'S VO�. DT- \\\n .4-1i ft- T 1 ft. /_D1/ ;(in. ,'23 MATERIAL pV
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)...''
JJ�� /� FROM TO DIAMETER THICKNESS MATERIAL
2,Well Construction Permit#: Z V- rj ` IL rt. 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
❑Agricultural OMunicipal/Public it. ft. in.
OGeothermal(Heating/Cooling Supply) i6Residential Water Supply f� it. in.
� � g PP Y) PP Y
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO c'MATERIAL • EMPLACEMENT MET OD&AMOUNT
❑hr n b ft. 'ID ft. � nlpn 1A'e )OUT el._Non-WarWater Supply Well: ft. ft. 1
❑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 ft. It.
• ❑Aquifer Test ❑Stormwater Drainage ft
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if-necessary)
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(calor,hardness,soiltroek type,grain size,etc.)
OGeothermal(Heating/Cooling Return) DOther(explain under#2I Remarks) cP ft- )69 ft. G Iu+ J f
4.Date Well(s)Completed: -2-5- -2 Y f t p t�' G i, C� / `��++� '" 1:y
5.Well Location: If3 ft. goe ft. SC7h stall -e- fc. ?wart l
91naNnew Ccl►r-A• ( oe U le.1 1 ft. ft
Facility/Owner Name Facility ID#(if applicable) fL
35 1 � - ft - _
Physical Address,City,and Zip c - ft ft r Z L�a V `x
21.REMARKS A
U'n\o`^ Cb-t24,--62 1 JUL ! 4 2023
County Parcel Identification No.(PIN)
lI'.t-r.r,'i•.11 17lre'":7t- t:'. Litt'
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: CAPt v IG
(if well field,one lat/long is sufficient)
//��, �� �� S 2s 23
3�J.CS�b5� N 'L�d i,��S� W �'le�Yriv�/��e:rcti'
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 12Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with ISA 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 fil'No copy of this record has been provided to the we/1 owner.
If this is a repair,fill out iomwn 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
S.Number of wells constructed: I 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. '''')) / 24.Submittal Instructions:
9.Total well depth below land surface: a%e+67:9 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(erample-3Q200'and 2Q100') construction to the following:
10.Static water level below top of casing: ej 1 (it) Division of Water Quality,Information Processing Unit,
If water level is above casing.use "I 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: ' e (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
12.Well construction method: ,Cr Vy 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
13a.Yield(gpm) Q. Method of test: U- 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
` the address(es) above, also submitIone copy of this form within 30 days of
13b.Disinfection type: 0' 1 4 Amount: 1 \'In completion of well construction to'the county health department of the county
1 where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013