GW1--06401_Well Construction - GW1_20231009

vvm4,L;l)fkIJ•1•KUC'j1(J J RECORD For Internal Use ONLY:
This form can be used for single or multiple wells .
1.Well Contractor Information:
14.WATER ZONES- . I
J-eFFr'ey C P/' /Offe411 Pr/.ty ' FROM TO DESCRIPTION .
Well Contractor Name ft. lt. /:2 C 3 41 0 1160
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(f ap licable) -
FROM TO DIAMETER THICKNESS MAC
2, 6. r cc/li's we// `art (0,-1 r- .zelic .11 It &0 " 6 *n• a/a 5 /'(IC
Company Name �J 16.INNER CASING OR-TUBING(geothermal closed-loop)
A FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: •
L� ft ft. in.
List all applicable well consttuclhtn permits(i e.Count}:State,Variance.etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
`' Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft.
°Agricultural °Municipal/Public ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) B' r"'
DlndustrialCommercial °Residential Water Supply(shared) 18.GROUT • •
-
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Dlrrigation 0 ft. AD it. I14aflD»t Non-Water Supply Well: t�P, �D L[! C�
°Monitoring ORecovery 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
ft ft.
❑Aquifer Test OStormwater Drainage
ft. It.
°Experimental Technology °Subsidence Control
20.DRILLING LOG(attncti•additional sheets if necessary)
°Geothermal(Closed Loop) °Tracer FROM TO DESCRIPTION(color.hardness,sell/rock type,grain size,etc.)
°Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 1:2- ft a o ft Reed e/d
4.Date Well(s)Completed: /G % 3 v .23 '2 O ft. 3/�v �O�C '/t'i t/�r�l,((e//
Well Location: 30 f Coo "it , `e.d r`oeA
1 Tn,V-1- .
s.� 6Qd it�t• /Cg `t � , ,�,,�,,�N
Facility/Owner Name FaciliryID#(ifapplicable) ! K'�-/ a7 e9 V 4.., G "'w)-
/l7 '70 6re•en Rd ft. ft
n n a �.
PAirt_
OY1 C6�O? q955cal Address,City,and Zip
Zl.REMARKS OCT V �1�� ,i
County Parcel Identification No.(PIN) in-4. ''`'" "� '1".j LIfr.>f
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(iFwell field,one lat/long is sufficient)
31/06/AA 6 0 N 80# .30/&,e w t�Ti• �-r /o-3-a3
ofCe ed Well Contractor Date
6.Is(are)the well(s): [i3'Fermanent or °Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: °Yes or 2filic.
copy of this record has been provided to the well owner.
If this is a repair;fill out!mown well construction information and explain the nature of the
repair under#21 remarks section or on the back of thisfomn. 23.Site diagram or additional well details:
1 Yon 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: 5 te9 0 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-4)200'and 2(0100) construction to the following:
10.Static water level below top of casing: 35 (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: 1.0 1/4 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
n above, also submit a copy ofIthis form within 30 days of completion of well
12.Well construction method: /t.O?L ct r y 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) ..5'
Method of test: A;r 24c.For Water Supply&G'thermal Wells: In addition to sending the form to
y' Z� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: / /T Amount:3 pj# '��' 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