GW1--06388_Well Construction - GW1_20231009

VVJSLL cuiNSI•ItUCTIONRECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
eF r ei �GC G/7 er-/8 • y� I4.WATER ZONES . .
i• I-� n / G�/ l� FROM TO DESCRiPTION
Well ContractorN a ft, ft, 15/tl 6/�
L7 6'©2 ft. f IJ O
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(idap licable)
FROM TO DIAMETER THICKNESS MATERIAL
22 tr .lyle,//t5 we</ 2rr'Cl i Z,r/c * / r7( E.%gin- ,/)_S /01/c
Company Name ) ` ' ! 16.INNER CAs3NG OR TUBING(geothermal closeddoop)
1 n�-1 /„®I 1 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: • lV 11t ((f Il ft. it in.
List all applicable well'construction penults(i.e.Countyt State.Variance.etc.)
ft ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Mu//nic�ipal/Public 4- !ft 6 of o- L f f7 in, ,4414 , /oQ 5 PVC
OGeothermal(Heating/Cooling Supply) l7�ICesidential Water Supply(single) ft
1O'
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT •
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation
•
Non-Water Supply Well: d ft: A 0 ft Y3eOi oil;A. p ce r ed .
ft. ft
OMonitoring ❑Recovery
Injection Well: ft It
❑Aquifer Recharge DGroundwater Remediation 19.SANDiGRAVEL PACK(if applicable)-
ulferStora StorageFROM TO MATERIAL EMPLACEMENT METHOD
DA
q g Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary) -
❑Geothermal(Closed Loop) ❑Tracer FROM ' TO DESCRIPTION(color,hardness,soiUmck type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) (' ft q O ft 3' ,e ,5 rL®n e
4.Date Well(s)Completed: 7 p-a () -.2_3 t�o ft. Q ft. / d /'a c/
5.Well Location: �O ft Road AO cif
�� �� [� • D ,t- 6 0 I2 i oc/� •
_.
;so sac- 93644, �� ,,,
Facility/Owner Name Facility ID#(if applicable) - =;
636 sandy 1 t iP C_ft ec ii / C� ft it to y`®..i.,,+ r ) _.
P I Address1Ci y,aan Zip
� ;C, !1 l \. � - V 2Q7gf(C16 21.BEMARKS UC 10 9 2� o !) V� 2023
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: G. Cyr>.,
22.Certification:
(if well field,one lat/long is sufficient) ,
35r+ 033oLi N 179g 7'"13Ss W -a6,a3
��' go o rtified Well Contractor Date
6.Is(are)the well(s): Dt anent or OTemporary By signing this form,I hereby certify that the well(s)war(were)constructed in accordance
with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: DYes or War"- copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the i
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.Number of wells constructed: / construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: () (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd/erent(example-3 00'and 2Q100') construction to the following.
Division of Water Quality, Processing to
10.Static water level below top of casing: (ft) Quaff Information Uni
If water level is above casing.use/"+" 1617 Mail Service)Center,Raleigh,NC 2 769 9-1 61 7' •
11.Borehole diameter: C'�� (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
/� ,,c above, also submit a copy of tills'form within 30 days of completion of well
,. 12.Well construction method: /1.a /G,-.7 construction to the following:
:,(i.e.auger,rotary,cable,direct push,etc.)
.?. Division of Water Quality,Underground injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service,Center,Raleigh,NC 27699-1636
13a.Yield(gpm) R Method of best: /1'y" 24c.For Water SIIDDiv&Geothermal Wells: In addition to sending the form to,__
_ �/ the address(es) above, also submits one copy of this form within 30 days of
13b.Disinfection type: / ` /7 Amount: 3 p,I')fs -
completion of well construction to the county health department of the county_
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013