GW1--04796_Well Construction - GW1_20230721

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WELL.CONSTRUCTION RECORD(GW-1) For Internal Use Only:
l Q'rre.'t't fPaation:
as// ct14:4VATER=7ANES7 ;_._: .u.t ,{? , r:, _ s•., �:;;�_:: .
Well Contractor Name FROM ft. TO ft. DESCRIPTION
1-1 5 q 5-A ft. ft.
•
N Well Contractor Certification Number 6,15:;01.1TERICASING`(faeiniiitknied we1L)ORtI:RQVERk(iflap lleable) ' .
s We1!!and Co• FROM
M ft. 13 0 ft' 6./DIAMETER in. THICKNESS 1 1 l/G
Compan Name
16:TNNER`.C'ASING:URTQBING,°(ge5thermelielosed=lo6p)`..,/.: : . S.'.:•s'
2.Well Construction Permit#: 0 3—2o23—/ C1/395 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft in.
Water Su 1 Well: ii17;SCREEN.<.'.f+ `,iAA,.` x., ,;;u,,. ,,., -:0.;, cot .. ., =a ;-:.'rt .,u. ,-
PP y n ZE
_FFM TO DIAMETER SLOT SI THICKNESS MATERIAL
Agricultural QMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. g. - In.
10Industrial/Commercial Residential Water Supply(shared) 18.GROUT .i:j e� �:.n;. ... .. ,,.r ., r
;, ,
Iriaation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. i•A®i-i b f0 Ba(74
Monitoring ['Recovery ft. ft.
Injection Well: ft. ft.
['Aquifer Recharge ['Groundwater Remediation
f19SSAND/GRAVEL PACK.(if applicable)4,4;•`....... e .; >1
'['IAquifer Storage and Recovery ['Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
['Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology ".\ ['Subsidence Control ft. ft.
Geothermal(Closed Loop) ['Tracer 1411:DRILLING i;O'Gi(attacti edillNonal aheetiOneeeasery): '.t.; t. , :_.
FROM TO DESCRIPTION(color,hardness,solUrock type,grain else,etc.)
['Geothermal(Heating/Cooling Return) 2 Other(explain under#21 Remarks) 0 •
ft ft. Chi
4.Date Well(s)Completed: 7-7-2 5 Well ID# 131 ft. .,.06' ' 6�ni
5a.Well Location: ft. ft. ! ,j'Co F "I r
CIc lowilbNt6s/6IIT I/v 6r/i6S �.�
ft. ft.
Facility/Owner Name 1 Facility ID#(if applicable) ft. ft. J��L 1 2023
/8y1 WGtS�v�► Or. Laf $ ft. ft. Information pft?C Liras
P sical Address City,and Zip ft. ft ' �`0QG
.01+a Wba :21°aREMARKS,`f . ...: V.. ,. . P: , x�_,t. ... ., .
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:
35.635.2? N -31. 117`/3y W ,G SA - , --n 3
Temporary Signature of Certified Well Contractor Date
6.Is(are)the well(s)1'Permanent or
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ['Yes or "No with ISA NCAC 02C.0100 or ISA 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: L 05 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths((different(example-3Qu 200'and 2Qa 100) construction to the following:
10.Static water level below top of casing:: CO (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 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
L above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: ga TCIY Y 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 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 20 Method of test: /'T/�1 M 24c.For Water Supply&Infection 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:Cu+Iorr n t Amount: 2 C(4/)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