GW1--05208_Well Construction - GW1_20230814

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: ..1.Well Contractor Information:
N 1, ' 14.WATER ZONES ' "
Well Contracta/r�Name[[ Q� FROM TO DESCRIPTION
NC Well Contractor CettificationNumber r �`' � �
ir
is.010TE casaYa tmrmuttz- eaweffs OH LIMA rtr mute)
(i / FROM TO DIAMETER THICKNESS MATERIALl'
/fame l.;f 'ZG r�I D ft. (n 3 ft. &,-4_? In. L5/) ZI PC
Company Name /�C' 1 f� •
16.INNER CASING OR TUBING(geothermal closed-Ioop)
r/2.Well Construction Permit4: sI)(l ')DCf1/- 2-2_ FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le_UIC,County.State,[variance.etc.) ft. ft. in.
r
3.Well Use(check well use): IL ft• in. -
Water Supply Well: 17.SCREEN
FROM _TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QM cipal/Public 0 ft- ft. in- -
Geothermal(Heating/Cooling Supply) = esidential Water Supply(single) ft. ft. hi. -
Industrial/Commercial DIResidential Water Supply(shared)
-
18.GROUT
Irrigation --- FROM TO _ MATERIAL EMPLACE,v1ENr METHOD&AMOUNT
Non-Water Su Well: ft- ft• l' ® / 4
p� � G�� ��� rl���f 1�, r v�-�e 7 G
- Monitoring ORecovery ft. ft. jlZ, t
Injection Well: f„ �a e •,r. y e
Aquifer'Recharge oGroundwaterRemediation Et. ft.
19.SAND/GRAVEL.PACK(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) E3Tracer 20.DRILLING LOG(attach additional sheets ifnecessaty)
t_•Geothermal(Heating/Cooling Return) (Other(explain under 421 Remarks) FROM TO DEscsrnrtox[om0.hatdnes.�;v,odrtyPGgroinsize etc.)�Q / 0 ft. ,2 ft. Ou(r t.rei el
4.Date Well(s)Completed: i--/b"2"Well ID# // 7i/ 2-9 �-7 1 ft• z c ft. (_c&/
So.Well Location: //( - S ft. .7-09 ft. eZi-L•,,i All-'Z
S ne P71 t , ft. ft. y- ._
Faoility/OwnerN®e Facility ID#(if applicable)
ft. ft. ` 6.1.-�w.,��.-i,'4:' '?.-.
/9.g Pei'7l y . r( G`C/1. x:L t? l//G ft. ft. A U G 1 z. ?023
Physical Address,City,and Tap Z?S-70 ft. ft,.
Pr�1Gl�t 21.REMARKS I� G:'ivl3,X,,
County ,, Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
•(if well field,one latilong is sufficient) 22.Certification: '
3 . ';q 1777, - N 7g- 3g.CDZ-9 w ( -c?�.�ci-%i . 1 (6 2-3
6.Is(are)the well(s) anent or E3Temporaty Si ofCerti ea ell ontractor Date
By signing this form.I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or EINo with 15A NCAC 02C.0100 or 15A 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 fonn. 23.Site diagram or additional well details:
S.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: Z 0 0 (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 ,00'and 2( 100) construction to the fallowing:
10.Static water Level below top()leasing: 2-- - (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. v (in) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: pets /
i- kl above,also submit one copy of this farm 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 f lW TELLS ONLY: - _ - -- 1636 Marl Service Center,Raleigh;NC 27699-1636
13a.Yield(gpm) / Method of test: vz+n /'-i-. 4c.For Water Supply&Injection Wells: In addition to sending the farm to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: i-f T1 1 Amountz 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