GW1--05771_Well Construction - GW1_20230901

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only: ,
1.Well Contractor Information:
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WellComractorName FROM TO DESCRIPTION
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NC Well Contractor Certificati n Number_ _ _
ReAkte 1 a, III E,t1 I 1 n5 �,in,e,,, FROM TO D LIECKNESS MATERIAL __1
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Company Name i „
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2.Well Construction Permit#: kJ G S- 0 at 00 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e./IC,County,State,Variance,etc.) ft. 'Al ft. 4- rn' Sae& PVC"'
3.Well Use(check well use): f' ft. t in.
Water Supply Well: : s di' %t.ft:r tI ,,t4-,TMftV, ,r P,�i W M`:AS4NK
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMuni ' blic ft. ft. in.
DGeothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
DIndustrial/Commercial E3Residearhd Water Supply(shared) , �,� Y y,,. r,�,,.. , .f
nIkrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMM
Non-Water Supply Well: :` U fr. ip ft' b- n , r ' .:'> 1,100
Monitoring Recovery ft. © fi' ��>'�S� ry1 i • O'AF�______ ,
Injection Well: •
A� g ft. f�A4Storage ey ty i oV"ii xkrrt
Aquifer az and Recovery
B ter Remedratio +- }FROM .
a r � _ ®�` re MATERIAL EMPLACEMENT METHOD
Aquifer Test DiStomiwaterDtagg 0 L ft ft. 1
DExperimental Technology DSubsidence Cogtrplp J 1 2023 ft ft.
Geothermal(Closed Loop) DTracer J CC , . 4
JGeo hernial(Heating/Cooling Coolfn Return) Other t FROM TO DESCRIPTION(color Ludness s Wrock type,grain sine,eta) _ _
t g/ $ ) (�Pt Ytlmd Pl Remarl[s' 1 ������ttt,,,,,, //����veir.
4.Date Well(s)Completed: 5 15 J a3 Weil lD# -1r1 ft.• .fl l ft. n�7 i'4'P ,
5a`.Well Location: T ^1 ,.•I f t. 'I /is ro /.try A/ CP 1 cS S'Q Ir \
-J„&�-pr 6 c•c c S 1 C ft. a�17 V�G ,r.:;-�- i
Facility/Owner Name Facility ID#(if applicable) ft• ft. I
I b 5S -bbl`. gam; h �� , `Wa03vltt ft. ft.
Physicai Address,City,and Zip lam' t` 1 ft' ft. t
CVGtiy 00od I i 0- 3 .- , oq5 "IttlW x"1 5 y
County 1 Parcel Identification No.(PIN) U &\' —e \ e'cLA ta...-.�
cl��-W`-- — Ce -tv1 a Y�1�y GA--�
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: )(NI!) �t(if well field,one lat/long is sufficient) 22.C`w 'cation: 6 '1 '�-- �.,._
N W \., `.�yl�^--- 5 8-4- ,3
Si_,: Well Contractor Date
6.Is(are)the well(s) Permanent or Temporary '
By signing this form,1 hereby certfy that the well(s)was(were)constructed in rdance
7.IS this a repair to an existing well: Yes or No with 15A NCAC 02C.0100 or I5A 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-pro-vide 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: a 6 ( ) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 6 o (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail ServiceI Center,Raleigh,NC 27699-1617
11.Borehole diameter: b GO24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: (Z.,.® 1\ above,also submit one copy of'this form within 30 days of completion of well
(ie.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 2 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) I Method of test: `"i S 24c.For Water Supply&Injection Wells: In addition to sending the form to
`V the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: �'N Amount: I Q 2. 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