GW1--06147_Well Construction - GW1_20230922

WELL CONSTRUCTION RECORD(GW-1). For Internal Use Only: •
' 1.Well Contrae Inf tion: ,
� jI
f°(Y Ire 14WA'E&ZONES ... • l
WeIlCo>maaorName FROM TO DESCRIPTION
JCv) .. ..
•
NC Well CoCertifificaaon Number • ..15:UUTER.CASING(form i-easedwdRs)OR LINER(d )
/� FROM . TO DiAM/EfER 1HIC[OV MATERIAL
Company N �1 � (�' in. /` �C .
�� -.va 9-) 2 •.1ROM 7TO UA . 1 )
2.Well Construction Permit#: FROM DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State.Variance.etc.) ft.
3.Well Use(check well use): 11 ft m.
Water Supply Well: FROM ToI DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 0 F lf' in.
111 ' ,fpGeothetma](Heating/Cooling Supply) idential Water Supply(single) 'V R in.
Industrial/CommercialRillillalion ()Residential Water Supply(shared) GROi>r:..
FROM TO MATERIAL EMPLACEMENT METHOD dtAMOUNT
Non--water Supply Well: ✓Oft CD.4e/- 1 • �o 0A i/. .
Monitoring DRecovety ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge
(moutidwater Remediation
19.SAND/GRWEL'PACKfif ble).
Aquifer Storage and Recovery D Salinity Barrier FROM ft. MATERIAL EMPLACEMENT METHOD
Aquifer Test' DStormwater Drainage
DExperunental Technology Subsidence Control ft
OGeotbertnal(Closed Loop) ()Tracer ':38:DRI LINGLOG.(asmehaddiraemul3Leeis.il'ae ry)
Geothermal(Heating/Cooling ) natter(explain under#21 Remarks) FROM T O Dix{rotor t,.ra,ess sm7frock qye grain sus etc)
4.Date Well(s)Completed: 0 /2J Well ID# 'D ft' NS
Location:5a.Well /(a( k C
.7,--.,,,-4ui (,/ f ft. '—.ter.'l .i LI
Facility/OwnerNamq / FactiityID#(if applicable) ft ft
r��G` Ar ,/ � ft. S b=P 9 2023
Physical City,and Zip ItI�J;il�ase77 t°rr. :xi ,g Uri
df :2LREMARXS v dC
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/winutes/seconds or decimal degrees: '^l
(if well field,one lat/Iong is sufficient) 22.Certification: !
N W C r`7 5 ( �—;
6.ware)the wells) Permanent or ()Temporary Signature of cd Well G�ontracior• / Dar
By signing this form.I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or DC with 1.5.4 NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out brown well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remar43 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if neca ssary_
drilled' SUBMITTAL INSTRUCTIONS
9.Total well /depth below land surface: / 09 5- (.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths dfdifferent(example-3 a(Q200'mud 2(01001 construction to the following -
10.Static water level below top of casing: V. (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+'/ . 1617 Mail Services Center,Raleigh,NC 27699-1617
11.Borehole diameter: /v (in.) 24b.For Infection 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: is-`:;' a/ 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
1
m) /
13a.Yield(gp Method of test: (f 24c.For Water Supply&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: (7 Amount:___LiO Z,.. completion of well constructionl to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016