GW1--06396_Well Construction - GW1_20231009

--- _An,/.4.J.ivt. ■%.EI .J1 1J l For Internal Use ONLY: i
This form can be used for single or multiple wells
1.Well Contactor Information: ‘
14e1 T `del IL 1 ei AV)n -TG C.kSca 14.WATER ZONES-
FROM TO DESCRIPTION
Well Contractor Name 150 f 160 ft.
26 3 6 ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER of up.liable) .
• FROM TO DIANffiy= THICKNESS MATERIAL
\'k.... 6\0\\'s \Ne\\ D r \\roc -4-1 ft- t 5' to gin- 1 12 S NC
Company Name 16.INNER CASING OR•TUBING(geothermal closed400p) •
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: • 3.dq 2 3 0 ft. ft. I in.
List all applicable well construction permits(i.e.CounV.State,Variance.etc.)
ft. ft.• in.
3.Well Use(check well use): 17.SCREEN i
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public H. it. in.
❑Geothermal(Heating/Cooling Supply) //Residential Water Supply(single) R' '"'
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT ; -
FROM TO MATERIAL • EMPLACEMENT M OD&AMOUNT
❑litigation
Non-Water Supply Well: 6 ft 2 0 f"eP bcct4e \: L
❑Monitoring ❑Recov�Y ft ft )
Injection Well: ft. h
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)-
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMBTROD
tt ft
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach'additional sheets if necessary) -
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(calor,hardness,soli/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) Co ' /® ft re,.
�e1 ci�� i
4.Date Well(s)Completed: el I 1 1 (2 )✓ to ft 4fd ft.
=t�t''� r-ed C�G�
6++ ft $Ct t!1C1f1;' t,c'1
i10l�Clt'I1 f'� ��A"�' jar) it' "LC)0IL ,et�ei$4-tine I
5.Well Location: ` .
Si ark e
Y ft.
_
Facility/Owner Name Facility ID#(if applicable) -
n ft I
`=:.--„ U a ‘,1 :--,--'
y '
c
2.20 ,5VNe./4,v.rt4 ft. ft.
Physical Address,City,and Zip 21.REMARKS 0 C T 6 9 2023
P.11 1664113 ei-A'3 Inf:-- .^ t v
County Parcel Identification No.(PIN) i G: - �v„
�/ii OG4.
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one let/long is sufficient)
Ss, (7,4z01 N eo, ,z438 w /K�/,//-fril) L1Iiii 12'3
Signature of Certified Well Connected Date
6.Is(are)the well(s): &Permanent or ❑Temporary
By signing this form,I hereby certify;that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: [Wes or li/No 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
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: I construction details. You may also attach additional pages if necessary.
For multiple infection 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: 20 6 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
-For multiple wells list all depths Id/erent(example-3@200''and 2QI001 construction to the following:
10.Static water level below top of casing: '1 0 (ft) 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: k,118 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
n above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 4-t 1 r- esi • 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: tic 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: l f 24c.For Water Supply&Geothermal 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: r�C'T Amount: \Ti‘rA 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