GW1--06421_Well Construction - GW1_20231009

r+y:rbua'i.vl1U1 ICU t.IIUl"I.DLE LIJKIJ For Internal Use ONLY: '
This form can be used for single or multiple wells
1.Well ContractorInformation: % . i
14e`V% 1 1 &C,V 1✓7 a G C d• I FROM WATER ZONES- . I
DESCRIPTION
Well Contractor Name I1 ft. 'ISZ ft.
2b3 6 - /Aloft 3 t. 1
NC Well Contractor Certification Number . IS.OUTER CASING(for multi-cased wells)OR LINER(if op,licable) - -
FROM TO DIAMETERTHICKNESS MATERIAL
PL L\`\S \e,\1 `Prk`1\nc� +1 ft. 1 of 6 tin. Z,C.' pv c
i 1
Company Name 16.INNER CASING OR-TUBING(geothermal closed-loop) •
1 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit ft: •F �W-z r• - ��"•l; is • ft. ft i in.
List all applicable welt construction permits(Le.County 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 ❑Municipal/Public 1°
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT M OD&AMOUN.T
Obligation
Non-Water Supply Well: 0 ft. 20 ft nun14+P f CA
❑Monitoring ❑ ry
Recove R. ft: 5
Injection Well: rt. ft. '
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)•
❑A nifer Storage and RecoveryFROM TO MATERIAL EMPLACEMENT METHOD
9 g ❑Salinity Barrier ft. rt.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tmcm 20.DRILLING LOG(attach'additional sheets if necessary) ' -
FROM TO DESCRIPTION(color,hardness,soWmck type,groin size,eta)
❑Geothermal(Heating/Cooling Return) ❑Oche (explainunder#21 Remarks) 0 ft: 20 j, c 1 G�j 1
4.Date Well(s)Completed: : \ 12® 2 J '20 f ga ✓ice �•iS� j7$G ve r 57'6 ne,
5.Well Location:
r p�f •
t3 �^_ ft- (00 ft. Sa► S re
VGrr} R ^ t. ci tr,a''1 i 1"C
Ilet,fft.. 42() f
ft.
Facility/Owner Name Facility ID#(if applicable)
-(1 sf ee% C ft. ft. ' �•-'
63D Qe
ft ft. x.r, tr k� -,t
Physical Address,City,Qnd Zip 21.REMARKS D f T 0 9 2023- '
Linco lm 3� -St-1
County Parcel Identification No.(PIN) i r f�.I r.=:.!1'a R;,;, l 1r S.
1 r'.h t'at3:Zr•
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: I y
(if well field,one 1at/long is sufficient) ,ter l ff�� I
SS C l OP 1 N �' t e6�l34 W i�"C(��i� i/,� ei 1 Z'o I 2 3
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 'Permanent or_ ❑Temporary
By signing this jornt,I hereby cerrify that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0I00 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or "'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 additionalwell details:
You may use the back of this page to provide additional well site details or well
8.Namber 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. 124.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 if different(example-3Q200'yand 2(a)I00') construction to the following:
00
10.Static water level below top of casing: -1 0 / (ft) Division of Water Quality,Information Processing Unit,
Ifwater level is above casing.use"+ 1617 Mail Service Center,Raleigh,NC 2 769 9-1 61 7
b �11.Borehole diameter: t(in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Nu-. 9-cAcvr-•1. 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: a 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) d Method of test: r 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
4-1- the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 4- Amount: ( �, completion of well constructionto 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