GW1--05171_Well Construction - GW1_20230818

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WELL CONSTRUCTION RECORD(GW-1). For Internal Use Only:
1.Well Con%'t
IRformation: %Y/t e' `� 14 WATER:ZONES
WellConuactorNtrme FROM TO DESCRIPTION
? oV� ft �ft ft.
NC Well Contractor C cation Number IS..UUTER.CASING(for wills)OR LINERfti • )
/r FROM DiAM THtCIINFSS MATERIAL
/ Uj ft9 ft• 6 in. i v L
Company Name
•16 INN&K,Ce15IINCG•f)R TITBINfi:.(Reottrermal did-leap)
2.Well Construction Permit#: FROM TOl DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. IC,Cmty,m .State.Variance.etc.) ft /�[ ft is
3.Well Use(check well use): ft 0. � �
WaterSn Well: '17:SCREEN` •'
pplY FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural EM eipal/Public 0 ft 1 /1 ft- in.
Geothermal(Heating/Cooling Supply) dential Water Supply(single) V/f ft in. .
Industrial/Commercial E3Residential Water Supply(shared) GROIFF .. ..
Irrigation FROM TO MATERIAL ® EMPLACEMENT METHOD&AMOUNT
Non-WaterSupply Well: ft' O ft' C0.4c/-K dertJn ' �4
Monitoring E3Recovery ft ft.
Injection Well:
ft ft
Aquifer Recharge QGroundwater Remediation
19.SAND/GR&LPACK iifapplieable)..
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test' QStormvrater Drainage ft / ft
Experimental Technology Subsidence Control V�it ft
Geothermal(Closed Loop) °i Tracer `20:DRILLING LOG.(auach add:tiermi shee s i ry)
Geothermal(Heating/Cooling Return) ,Other(explain under#21 Remarks) >RO`M TO r Day/N(color, sw7hvck type,grain me etc.)
4.Date Well(s)Completed: 5 4, / Well MI ,s ft VO_5'-ft /t D cir
5a.Well don:
"ft ft L(v� � 1 111'°'a
/�J ft. ft �b N l.m
1(tft ft. _ HUG 1 s 2n29
Facility/Owne
r
Name y Faedity IDh(ifapplicable)
/5.e - -/ ft. fL1P iCfi�:sfi^n ra.�°/ r
Physical ,City,and Zip flu fc d�r`4.?rjro; f� 'R]
2L REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: j ` -.
(if well field,one la/long is sufficient) 22.Certification: //
W A t'//S//Y
6.Is(are)the wells) ent or EpTemporary Signature of Certified Well Contractor form. Date
By signing this rm.I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well ®Yes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out brown well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 421 rents lrs 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 nerP nary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1/0 J (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ttedifferent(example-38200'and 2(@100) construction to the following:
10.Static water level below top of casing: 00
�l) (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
IL Borehole diameter. 4 (in-) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: C e' 5 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
• 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: r- ,C 24c. For Water Supply&Injection Wells: In addition to sending the form to
j'7 2/ J Amount the address(es) above, also submit one copy of this form within 30 days of
13h Disinfection type: /� U 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