GW1--04901_Well Construction - GW1_20230728

RFrii*Ftt
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: .
1.Well Contractor Infoj matron:
(.: 6t.r evA_41 e—ti {i14:WADER°ZONES.: :;z ti ;1,.: „ ..
Well Contractor Name FROM TO DESCRIPTION
''// it. ft.
r7'�.5-T A ft. ft.
NC Well Contractor Certification Number ( � /I /� r15:iOUTER,CASING?(forAmulti=///eheed wall#OR LLINEltelltap'lleablle,)r/� -
nu/K t )) ` ipkv'` �,) d—nc., FROM ft. TO Q ft. �ji METERL7. HI tKKS MATERIAL
;2j1 1 V
Company Name / / f
/ �y�y ;1'6�1NNERlCAS�GdOR�.TUBINGi(geotlieiirial cloeed=loop)t - ;� 'ti=-. ..
2.Well Construction Permit#: / 6 /I ) / / FROM TO DIAMETER THICKNESS MATERIAL .
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): [t ft. is
Water Supply Well: ,,17itSCREENkt L<�9.-r-. W K; ...:, b, ,srts,.tti..•<:; ,;:
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public tr. ft. in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
Industrial/Commercial _ OResidential Water Supply(shared) b„le:GROUT:x.,,.r,i_.:.. fi :Vrs r,::. . , a..5.r. s,:m t
Irrigation FROM TO MATERIALI r EMPLACEMENT METHOD&AMO
Non-Water Supply Well: a ft. �o ft. YJt'1ti(t✓Yil tC 14 -pato-Lel
Monitoring (Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge 0 Groundwater Remediation
191SAND/GRAVELiPACK(If applicable).,._;
Aquifer Storage and Recovery IDSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ` ❑Stormwater Drainage h• ft.
Experimental Technology 0 Subsidence Control ft. R.
Geothermal(Closed Loop) OTracer r:20 DRIL•L+INGLOG(ettacti odditional'aheets'if neceesiry) :? h :,,,1J
FROM TO DESCRIPTION(color,hardness son/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
- �/ �1, d 1 ft. 4-. v I-, Ala/
4.Date Well(s)Completed: !—/?-�✓ Well ID# `gI O ft' Lf 6 it j vta ji i fie
5a.Well ocation: ft. ft.
ifoPj <S -,0' OY( ft ft. Q %+k.e'k,f A..i V 1....1..)
Facility/ r Name Facility ID#(if applicable)
_ L5� (--;rpV e,s ft. ft. 11 2023
Physical AdoJJre ,and Zip�D fw i4 ft .. y
i�-II(� ,/� •�21EREMARK5 ltnt,!lr � /iPs g t.:t•n,`. . :< ,+'
County Parcel Identification No.(PIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:'
(if well field,
.one
rlat/long is sufficient) �{ r' / 22.Certification: -� ) g
3�i '7 `�LSc N I �7 W � / ,' %%�L 7 y--9..7
ermanent or
Signature of Certified Well Contractor ,if Date
6.Is(are)the well(s) Temporary
By signing this form,1 hereby certlfr that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or No • with 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this it a repair,fill out known well construction information an 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: 45" (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 00'and 2®100') , construction to the following:
10.Static water level below top of casing: q-C (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: 67 (in. 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: VI I
(in.)
above,also submit one copy of this form within 30 days of completion of well
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
t
13a.Yield(gpm) t i Method of test: 4_1 Y' 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:. W�L .'ri ne,Amount: t_ Ga-- _4 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