GW1--06422_Well Construction - GW1_20231009

IT lCLL WINS I RU C77UIN RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: k
toe\v\.. % lV- ( `n ail,r1 C.F�� 14.WATERZONES - ••
FROM TO DESCRIPTION •
Well ContractorName 1411 at. ft,
I
..2.6, b lift tL I
NC`Welll Contractor Certification Number \ 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable) -
CL. 1 \V"\ ] e\ r‘\`\ FROM ft TO It DIAMETER in. THICIG�IFSS MATERIAL
Company Name 16.INNER CASING OR-TUBING -
(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit##: • 3 2. d I I ft ft. in.
List all applicable well construction permits(1.e.Countjt State,Variance.eta)
ft. ft in.
3.Well Use(check well use): 17.SCREEN
" Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
I7A cultural ft ft in.
Sri ❑Municipal/Public.
❑Geothermal(Heating/Cooling Supply) fiResidential Water Supply(single) ft I In.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT OD&AMOUNT
❑In7gatioII
•
Non-Water Supply Well: 0 ft c-2:1;) ft pae,
OMonitoring ❑Recov ray ft. ft.
Injection Well: ft- it
°Aquifer Recharge ❑Groundwater Remediation 19.SAND!GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
n ft. i
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
°Experimental Technology ❑Subsidence Control
(Closed Loop) ❑Tracer 20.DRILLING LOG(attach'additional sheets ifnecessary)
❑Geothermal . '
FROM TO DESCRIPTION(color,hardness,soImck type,grain size,eta)
❑Geothermal ft. ft: jd. a�q l(Heating/Cooling Return) ❑Other{explain under#2t Remarks) 0 �� � (a/�t
4.Date Well(s)Completed: q'"I d.-� � 20 ft I t o ft sghcl i sa SA-One
5.Well Locatiqn:
I '1D 44SOft 9f-airlIjte.
Pc.."e To,e,ot,1'.-66,-."$6
Facility/Owner Name Facility ID#(if applicable) iL ft t^`•;"'f , ,,; �.-.
Ib4 Scca>h•� Di- • ; `1.. -m,.
ft. ft: OCT r •-
physical Address,City,and Zip 21.REMARKS J C+ 0' .7 I f 12 j
"t r-e t 2Ibz4 ' 2.3 "bleg tr, ,-r r1 ,:: � .,.:
County Parcel Identification No.(PIN) -.-,."A.•-2(Jr*
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one latllong is sufficient)
'' S S6/S2 N eon Gj'�-I1'"1 'i w . zee I <� - q - - ?3
Signature of Certified Well Contractor Date
6.Is(are)the well(s): @R'ermanent or °Temporary gy signing this form.I hereby cerafy,that the well(s)was(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 BM copy of this record has been provided to the well owner.
If thls is a repair,fill out known well construction information and explain the nature of the
repair wider#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 infection or non-water supply wells ONLY with the same construction,you can
submit one form. i 24.Submittal Instructions:
9.Total well depth below land surface: i LI ` 7) (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdifferent(e_rample-3Q200'and 2Q100) construction to the following:
1 I
10.Static water level below top of casing: ( ) Division of Water Quality,Information Processing Unit,
' ((water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11,Borehole diameter: / (in.) 24b.For Infection 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: (s".
//�� fir"' V.CA-0.1""si construction to the following: j
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) I Method of test: tt^ 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:
A
Amount: 1tt''i
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 WateriQuality Revised Jan.2013