GW1--05772_Well Construction - GW1_20230901

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only.
1.Well Contractor Info tion:
l
• Well Comtacbr Nerve
Z IC FROM2•'_ilill D.1-' I ON
111 r
NC Well Contractor Certification Number . . , --. .-_
L ('( - uweiVl, Ci?Y,r..i ) V., A,e (I. t M E !v:INN.O•ktji Co yName l �a 4 SeaEXLCOMi
2.Well Construction Permit#: in SS O 6 riloM NEEmml /1,.!,,Y.A(♦fir. cei0J
List all applicable well conduction permits(i.e.UIC,Cowry,State,Variance,etc.) R ft. 1, in.
3.Well Use(check well use): . '. it In.
Water Supply Well: gErzmig5 -- , ;n ` '
'cultural OM • al/Public !t. ft. riol -
Geothermal(Heating/Cooling Supply) 'dentin!Water Supply(single) o. ft. to. _
Industrial/Commercial Residential Water Supply(shared) . ..`" ;' . R Irrigation P 'sr, I t'2' I PROM �! r v IVA 1%1 s ,i CN, 4 !Y r e I:M Y uI 7�, m o 111
- Non-Water Supply'Well: - ,• 4\! :• ''"• 9 immur T k
Monitoring ORecovery SEP 1 2023 ft. ft.
Well: •.0
Aquifer Recharge r rr L! r e�f2,tS�
JAquifer Storage and Recovery OSalinity Barrier IT-0G ®® I' �F; 3'` ' .�,.z .i -
l� Y 1 l�I,�1•s[Y1d,',IA•Y�.•;Ii1Y;G)1]_
OAquifer Test OStomtwater Drainage . . ft. ft j` .
Experimental Technology OSubsidemce Control ft. ;.
OGeothemral(Closed Loop) OTracer -;. ,. ' . , .., ., 1 .`t i ^~r• '` �"
s'
lim
jGeothemral(Heating/Cooling Return) [Other(explain under#21 Remarks) Y� 'J. 1", I.17f. rt-�*�nr•-�z„ . -r„-�
0 f' MU J verbwra.6
4.Date Well(s)Completed:I/1 Qj
Well ID# e . _s
5a.Well Location: • 10 e`� C Q v i C2- \ . •�\
,.ral tr. s
04- LA ...
Facility/Owner Name • FaciliityPD#(if applicable) - • ft. it:
CN2
ft.
17
�' �,�� �— t� ft. ft.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .P
(if well field,one lat/lon ��) 22.C t cation:
'2 50. 3 '8 is1 // x a O �� w :�
1 �eJt .-- --( ►3 Q`3
OTernporary -°s•_, :• Well Contractor -
6. By Is(are)the well(s)0(rmanent orBy1 is form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or No with 15A NCAC 02G.0100 or 13A NCAC 02C.0200 Well Construction Standards and that a
If this is arrpair,fell out known well construction information and explain the nature of the copy ofthts 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 detals. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS ;
9.Total well depth below land surface: (f0) I;
P 24a.For An Wells: Submit flue'form within 30 days of completion of well
For multiple wells list all depths.Vdii different(example-3@200'and 2(41001. ,
construction to the
i
10.Static water level below top easing: Q (ft.) Division of Water Resources,Information Processing Unit, '
limier level is above casin&use"+" I I 1617 Mail Service'Center,Raleigh,NC 27699-1617
( I
11.Borehole diameter: (in.) 24b.For Infection Wells:-In addition to sending the form to the address in 24a
12.Well construction method: (1....creF k--- i
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: (� 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: e i 24c.For Water Subtly&Infection Wells: In addition to sending the form to
` ' the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: �i I I4 • Amount: 1 0 Z completion of well constructioaqo'the county health department of the county
where constructed. . ,
Form GW 1 North Carolina Department of Environmental Quality-Division of Water Resomef I es Revised 222 2016