GW1--06311_Well Construction - GW1_20230926

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: ,
1.Well� Contractor Information:
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Well Contractor Name FROM TO DESCRIPTION
©�3^ t ft. 3 Irit. !/jail° w
f3o ft- yt/fft. 1- 11o(- )
NC Well Contractor Certification Number -.15:.OUTER'CASING(foi•=mitltl=ciised Wells)OR LINER(if ap livable)`-
,ri �� ^ Lo-f „ Q a ' C. FROM TO D1AhiETER TffiCKftE93 MATERIAL
hF ,.J VLip.�( ft. ft. I � in.
Company Name I ¢'( .16.:INNER CASING OR TUBING(geothertimldosed-loop); . "` _ " '_
W``
2.Well Construction Permit#: P a 0 - D v J� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) O ft ) ,r ft 6 •ZS-in. 1)C n fJ 21 v c.
3.Well Use(check well use): ft. ft. in. ✓1� /
Water Supply Well: 17C SCREEN`'''
FT Agricultural
TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural °Municipal/Public I ft, ft. in.
in.
T Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft.
t ?Industrial/Commercial Residential Water Supply(shared) it3.'GROUT
_.plrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft. cs7d ft. 11„t;hd e Po p
Monitoring f�Recovery ft. ft Ct�i
i
jection Well:
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. ft.
Aquifer Recharge
Groundwater Remediation19.SAND/GRAVEL-PACK(if applicable)- - - " - -
Aquifer Storage and RecoveryO
(Salinity BarrierFROMToMATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage it ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) I�ITI8et r "'20rDRILLWG.LQG(attach'additiona1sheets'if necessary):- -'
FROM TO DESCRIPTION color,hardness,soil/rack type,grain size,etc.)
p ft. /Dr-ft -CI ay OCrlo rcie/k .
4.Date Well(s)Completed:q'2.0- z 3 Well ID# /sue ft 5ar'ft. tra 4 t s I r2
ft. • ft.
5a.Well Location:
,f t-� '4Relk On tla t1��) ft. ft:
Facility/OZner Name Facility ID#(if applicable) f t , 'ft. L'` .1::4„r� .)1 \r L.e.°
ON +l�r� Rd , I�SSO I Ovr.Si-1 .21'76� - ft. . n. SE " C '023
Physical Address,City,and Zip ft. ft. 1 W 9
-TYCOns y ivrthtc °N UR • I I - -Nei- :-21.:REMA12ICS: :_ a .__. -in1^:.'-- it-i?r r vn'.� .1 t Ir"(-., _ .
County Parcel IdentificationNo.(PIN)
Craw��v
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat./long is sufficient) �i 22.Certification:13so ILO1G•93t/42v/N gaZO Jg1 '�1. 17��7 u/t W s� t
6.Is(are)the well(s)MPSrmanent or EITemporary ignature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or °No - with 15ANCAC 02C.0100 or 15ANCAC 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 1/21 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 details. You may also attach additional pages if necessary.
drilled: CTTRMTTTAT"TNCTRTTCTTfNR
9.Total well depth below land surface: .5 O S (ft) 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@.1 00`) construction to the following: f
10.Static water level below top of easing: L/0 (ft.) Division of Water Resources,Information Processing Unit, -
Ifwater level is above casing,use"+" 1617 Mail Service'Center,Raleigh,NC 27699-1617
11.Borehole diameter: i,, 2S (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: 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 27699-1636-13a.Yield(gpm) g2. Method of test: qQ I. Craihi-0,h JC 24c.For Water Supply&11lection Wells: In addition to sending the form to
�J t_._ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Ml(ClerKe.. Amount: 5 1 Lb completion of well constuction�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