GW1--05755_Well Construction - GW1_20230905

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WELL CONSTRUCTION RECORD (GW-1) ' For Internal Use Only: I
1.Well Contractor Information:
(_-_-_,. /( Y' �I S19.t1'9Y/1rF,ER+ZQI�'&r4r�'},'Cs:.;�'dCnkfl'6?'s r�9 �.a.nNfF��:��R�'art�h v'. `'i!.,.::�f.3?3.�o..e�x ei y°
Well Contractor Name `Jl FROM TO DESCRIPTION
ft. ft. I
NC We 1 Contractor Certification Number 1
CoONER(GASIN•G(fd'riau)tkaie�Iti eA)it?R?IIINt1Ri trp`&a1Ue)P r„
p iy(o: 'A)e-) ) Pa-r7 ! il /,�G r M TOO DIAMETERTHICKNESS MATERIAL
Company Ne l� /tl (6 J f. /r /a/J m Q Y c., 1' F'C
/ ;4631NNERlcrASEVOIOR`mB(DINGf(Re` lieT likroe@d 11$014 Y>.a�s acYAV•rs: iii aj::q
2.Well Construction Permit#: W FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): • ft. tt. In.
Water Supply Well: /a17 SCIREENPm1+;1" „*Al t06,zaaje +l' ;_�I;f,_ :f, .><ir0 ,: : >scWP;;i,-
III Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS ' MATERIAL
l QMunicipal/Public ft. ft. In.,
•Geothermal(Heating/Cooling Supply) Elltesidential Water Supply(single) ft. ft. o.
•Industrial/Commercial °Residential Water Supply(shared) x,,,.. �v
Irrigation .1>isGROtIg' ;.g�i's»�.ijas''�.t.�`�':sld�i „')1.iii`S>t' tgS ,.�t°:.rC.�1vi� >tt i,::
FROM TO I rMATE+RIA EMPLACEMENT METHOD&AMO NT
Non-Water Supply Well: - t� ft' - 'h ., ft. {�('"i1 {�•-{'L1 to /.l AR C tAr
I Monitoring Recovery ft. ft. I
Injection Well:
ft. ft.
II Aquifer Recharge °Groundwater Remediation
I9 SAND%GEtantlPACK(ifiap pUcrible) ,. 3e:4aFn?ft_?xrT r.< :t.;.,
■Aquifer Storage and Recovery °Salinity Barrier PROM TO MATERIAL EMPLACEMENT METHOD
•Aquifer Test `.°Stormwater Drainage ft. ft.
1
■Experimental Technology .,\°Subsidence Control ft. ft.
•Geothermal(Closed Loop) Tracer e i i r,• r d
° t:'2O:I)1tYI.LING:tLQC+k(attefhtaddit(Qfipltilree6'ilf•gaces$oilyWAIW.:s+ ,.„Mi{,`k•si
■Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) FROM TO DES,- .. N(color;hardness,toll/rock type,grain sire,etc.)
a ft. 14 q 1t• dirt c,1 al
4.Date Weems)Completed:�''�'T p�-� Well ID# p h. U �'ft. ti�a� ��
5a.Well Location: ft. ft.
1�Ett;i r�s `T br--ne, ; Fc c .*t cv t u
^-Facility/Owner Name Facility ID#(if applicable) ft. ft.
f ' I, r JC-r it v� 2OLJ
-J� 3 -rid) l c le ix.) r1—iitrI i n 0 1 r R. ft.
Physical dress,City,and Zip L,)� 3�v g ft ft. • Info ale4ic a Pro' oaos4-t Unit'
d i,o�( I 21;RE.AR ,.,';a, . €!. .- t ,, %9.0...C"wsti tr .,
County Parcel Identification No.(PIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(if well.field,one lat/long is sufficient) / xt �j 22.Certification: j
� O�'�'�.
�7 OfJ 11l L) r (p u Q��pC W
'.taJI/V,:e%,/,11 yY,Lei. g-,50--. 21
• 6.Is(are)the well(s)[§Permanent or °Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certf that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or EDNo with 1SA 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:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
• drilled:
rSUBMITTAL INSTRUCTIONS
1
•
9.Total well depth below land surface: 3 o 6- (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd fferent(example-3Q200'and 2@100) construction to the following:
gI 10.Static water level below top of casing: (ft.) Division of Water Resources,Information ProcessingUnit,If water level is above casing,use"+'
1617 Mail Service Center;Raleigh,NC 27699-1617
11.Borehole diameter: (In,) i
24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: rdfi -t/ above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) // construction to the following: I
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Unde`rground Injection Control Program,
t 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1
Method of test: Q/1"' 24c.For Water Supply&InlecHoa Wells: In addition to sending the form to
I i )) G(4 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: el/10 it .1 6Amount: ...,2C ' completion of well construction to the county health department of the county
where constructed. I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i; ; Revised 2-22-2016