GW1--06389_Well Construction - GW1_20231009

xxa+a.ttL%..vt.v011LU1....1iUf 1CLl:VKU For Internal Use ONLY: 1
This form can be used for single or multiple wells
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1.Well Contractor Information:
///��� //,�++ -Tucker- /� ��JJ 14.WATER ZONES- .
• F-f e 1 , /./�, an / �"/ L P FROM TO DESCRIPTION •
ell Contractor Name ft, ft, 75 ^ ' i 7 0
Li6 0 �( J
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER of up licable) -
FROM TO DIAMETER THICKNESS MATERIAL
Ve L, /7)e .///°s r,alP!/ GIJr;L(,'y 1vr/c '- I ff. eft. 6',�/15in' , lA5 to tic.Company Name 16.INNER CASING OR-TUBING(geothermal closed-loop)
�/ / FROM TO DIAMETER THICKNESS MATERIAL s
' '! £,
2.Well Construction Permit#: • 3 • ?5 - a fr. Ft. in.
List all applicable well construction permits(i.e.Countyt State.Variance,etc.)
I. ft. in.
3.Well Use(check well use): 17.SCREEN
` Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft.❑Agricultural DMunicipal/Public R' tO
['Geothermal(Heating/Cooling Supply) L9t�esidential Water Supply(single) 1n.
❑IndustriallCommercial ❑Residential Water Supply(shared) 18.GROUT - '
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑I rigation •
a J
Non-Water Supply Well: tt: U ft VCn TOh,Y(P ioO u/P
❑Monitoring ❑Recov�Y ft. ft.
Injection Well: ft. ft.
°Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)-
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
iL ft. 1
[Aquifer Test ❑Stormwater Drainage
ft. ft. I
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attacb'addidonal sheets if necessary) - 1. •:=
❑Geothermal(Closed Loop) ❑Tracer FROM ' TO DESCRIPTION(color.hardness.soWrock type,grain size,etc.)
°Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) Oct• Q O ft: Reid C`.t./
4.Date Well(s)Completed: 7, /9 .23 Q 0 iL 5 a pOE€y et4t y//?L� .,.5 La
5.Well Location: 50 it: ,5 8' ft t ,v64'p s
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ChucK I oo-i-Dn' 5 g f 3°Oat Ve4.e G�
Facility/Owner Name Facility 1D#(if applicable) fL ft
r'^:. s"'; ,. re-.,.,.,,
/ a I aCftxv n 12d ft. ft. _ i..a,•a::: _.#
Physical Address,City,and Zip
21.REMARKS OCT 0 3 zo23
Kickmofid . 1+1°t00 County Parcel Identification o.(PIN) inf3rrr=r."f.';1 ?r:-•:-z:q,: 7 Ut;:l
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: la e.s�L113
22.Certification:
(if well field,one lat/long is sufficient) t-�
33-a l l 608 N / ,o 66 0yo2 w %cam o„ '/�'!a.3
Sign of enifi ell Contractor Date
6.Is(are)the well(s): Drectnanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.OI00 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or WK.; copy ofthis record has been provided�to the well owner.
If thts is a repair,fill out!brown well construction information and explain the nature of the
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:
J
9.Total well depth below land surface: 0 0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths IIfdijferent(example-3Qa 200'and 2Q100) construction to the following.
10.Static water level below top of casing: J a ( ) Division of Water Quality,Information Processing Unit,
' If water level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: & /"ff (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
/� 1C1 r above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: i 1 O/ � 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
f r 24c.For Water Supply Si Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) lV Method of test: t the address(es) above, also submit'one copy of this form within 30 days of
13b.Disinfection type: 1T T /i Ainountz 3 19i'Il S 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