GW1--05791_Well Construction - GW1_20230901

WELL CONSTRUCTION RECORD(GW-1) ' For Internal Use Only:
i
1.Well Contractor Informs n
'Ci ,0--Cinn 44 a a rs 4* o f
• FROM TO DESCRIPTION
Well Contractor Name
91 .-a A - - __ __- _115--II- Mt-ft- e,Al:c.cC� - _ S __m
Well Contractor Certification Number A 15 ft. al 9 Oft' c-c f.•1 u ot, - (Y\
e;
e rl to `��(/► IN
%U V ( k t ne FROM TO DIAME THICKNESS 4 MATERIAL
11--"��t 1 ��ICCC.. V� V •`v © ft. 6„6 ft. 6',/ in. s.ae ey
Company Name �..
2.Well Construction Permit#: 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): it' ft F 1O'
Water.Snpply Well: ..; %- ' i ' *-" zK„' eate { '
FROM '. TO DIAMETER SLOT SIM THICKNESS MATERIAL
Agricultural DM ipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) idential Water Supply(single) ft. ft Pl.
Industrial/Commercial °Residen�lWAeprSupply'(,shared)r �, i.� . $r „ ,A. y.
Irrigation . r' A •( P wI__n 68J h.&• .FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: •� ft °�O ft. 1.Df V (� 1�j
Monitoring Recovery S P P J 1 2023 ft ft. (Ai 11Pari)ease..-&.--,1Injection Well: ft. ft
Aquifer Recharge OGroun(} efry8ep��tra�froE�-q l I. a
yv'd!T't`sl.rtts t k�i iV'ak#ii it li*TIK "; 'ke tq '5Vtfpr' rA'r" M
• Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft. .
• Experimental Technology °Subsidence Control ft. ft. -
Geothermal(Closed Loop) Tracer 0 +.,, ^^ `d 4 it I O i` ' "? -1. -.
TO DES ON(color,I,anlaw,soWrocictype,grain,Ize etc.)
Geothermal(Heating/Cooling cram) ()Other(explain under#21 Remarks) FROM •
4.Date Well(s)Completed: Well INft• 1, . sr-v; •
5a.Well Location: 1 i s ft' \&Z it/ ( - i 1 Cf `t s 3
r V • r+ c'I1 )lq\-A vy ©ft. '-1 �/'r- -c-�..,,-�,3 .
Facility/ Name Facility ID#(if applicable) L16ft. aim ft. c('�1f'`CI"- Q' .s" PP.\
16 (... GYM agg-tt , s N \k oe 0-Z ° ?,a-o ,C�-ram;, - 1 �.
Physical Address,City,and Zip I ft. ft.
r1(\6a, Sr0- 61156`b g-8ff44 ; h NI
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22. • i cation:
' S° fig./ 4-0 tr N a ° 3V-1 // W \ c b (5
/ S
6.Is(are)the well(s) Permanent or °Temporary Si a Well Contractor D
By signing/this form,I hereby cert fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or rt o • with ISA NCAC 02C.0I00 or 15,4 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.Elk diagram or additional well details: - -
You may use the back of this page to provide additional well site details or well
S.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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ® (f.) 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 2Q100) construction to the'following:
10.Static water level below top of casing: 6. 0 (ft.) Division of Water Resources,Information Processing Unit, •
If water level is above casing,use"+" PP 1617 Mail Service Center,Raleigh,NC 27699-1617
• 11.Borehole diameter: b (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: R"—O "G--r- •Aconstruction to the following.
(i.e.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: • 1636 Mail Service Center,Raleigh,NC 27699-1636
_3_____ 1
13a.Yield(gpm)- \ Method of test: 24c.For Water Supply Si Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:. i- �� Amount: \ b a 7,a completion of well construction tol 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