GW1--05912_Well Construction - GW1_20230918

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor
d /14 f' /l_rl t�/J 14.WATER ZONES 1
Well Contractor Name FROM1 r TO DES/ iIPTION L
il� l/1 ,3,jft. 3fb • �.J'Hie 7 a '( 1 ` t���'�''
ft. ft. v
NC Well Contractor Certification Number
` 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
ncL, if f firtymenj I/n a FROM TO DIAMETER THICIQIF�SS MATERIA
, Z .ft. �y{ ft. ,..,,4 in. 11ie
Company Name
16.INNER CASING OR TUBING1(geothermal closed-loop)
2.Well Construction Permit#: I CO 13 lo 2 a- 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. ft. in.,
Water Supply Well: 17.SCREEN
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
QMu.'pal/Public 0 it. ft. in.
,.Geothermal(Heating/Cooling Supply) ME •esidential Water Supply(single) ft. ft. in. -
•Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. ft. i pot,' y-' UU7 pn
•'Monitoring Recoveryt' 6�
ft. ft.
Injection Well:
*Aquifer Recharge O Groundwater Remediation ft. ft.
IlIAquifer Storage and Recovery I Salini Barrier 19.SAND/GRAVEL PACK(if applicable)
ty FROM TO MATERIAL EMPLACEMENT METHOD
®:Aquifer Test 0 Stormwater Drainage ft. ft.
*Experimental Technology DSubsidence Control ft. ft.
•Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary).
i -Geothermal(Heating/Coolingg Return) Other(explain under#21 Remarks)
FROM TO DESCRIPTION(color,hardness,soi/rock type,enin1size,etc.)
.:J 1 /�3 0 ft. t9 a ft.
1; 0. --- C i�^ ,5.co)
4.Date Well(s)Completed: Well ID# Lo.ft. rL" l•r ft. 3 r°Al rec if
((( u,f . i�,rt
5a.Well Location: t,,j ft. /co ft. 1 ray rC
Facih /Owner Name( f- ft. ft.
Facility ID#(if applicable)
L»112, 7G e 4�,t')�, �j + J►{ 1201 ft. ft. i"t.'6.-I.."ii... 1:' I-
Physical Address,City,and Zip • ft. ft. •P S F D 1 8 Z1123
+I{1 t^� •s-6,1-
County ParcelIdenti&cationNo.(PIN) 103:11",&li:T.i) Pr'.;.ay ,,'�a3 U.r
y
21.REMARKS f DieLj U4.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient)
2 ertification•;
N i /
W
6.Is(are)the well(s) Permanent or Temporary Attire ofCertifi5 .7..Vw.:.?-7;
oafracror Date /
By signing this form,1 hereby certt&that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: EjYes or _ No with I5A 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 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:
SUBMITTAL INSTRUCTIONS ,
9.Total well depth below land surface: ) `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-3Q200'and 2Q100)
construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing.v '+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: to (in.)
24b.For Iniection 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: construction to the following: '
(i.e.auger,rotary,cable,direct push,etc.)-
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
,vim
13a.Yield(gpm)e�.� le-
Method of test: /9,'I a t . 24c.For Water Supply&Iniection Wells: In addition to sending the form to
y the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: { '! I4C Amount: completion of well construction to'.the county health department of the county
where constructed.
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Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources' ' Revised 2-22-2016