GW1--06495_Well Construction - GW1_20231013

WELL CUINSTKUCIWIN KLl'CIMUJ For Internal Use ONLY: V
This form can be cued for single or multiple wells -
1.Well Contractora Information:
G.J lt�Jt� /j//, /A/...... FR14.NATERZONES .S .I 1 S r/GG FROST TO DESCRIi'770NWell Contractor Name /fe0 ft Z.0 C2 I 1
2.0 55 z6 ft , Oft.'''.
% /
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased welts)ORLINER(if ap liable) .
•
All,
ll r FROM TO DIAMETER THICKNESS MA
/'d ll, LJQi/ 1 All i '74/ n 95it. 6%I in. ,/2� 7.116
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Company Name • 16.INNER CASING OR-TUBING(geothermal closed-loop)
/
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: �2 / U Z. ft ft. DIAMETER
in.
List all applicable well construction permits(i.e.County;State,Variance etc.) it ft i in,
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM ft. TO ft. DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural %a cipa1/Public
ft fL tin.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single)
❑Industrial/Commereial ❑Residential Water Supply(shared) FROM
FR TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation ft. ft. 1 -
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery ft. ft.Injection Well: i
❑Aquifer Recharge ❑Groundwater Remediation 19;SAND/GRAVEL PACK(if applicable)•-
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft. 1
❑Aquifer Test ❑Stormwater Drainage ft. i,
❑Experimental Technology ' °Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary) -
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCH ON(calor.hardness,soil/rock type.grain size,etc.) .
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft /0 rt / A c/..
ld ft W ft' 0(S9 t,/,e,
4.Date Well(s)Completed: r ZD it 40 ft. /14 e, S/w�
5.Well Location: R. ago ft ��/tl& 5�-1G
// C/ f. ft.
Facility/Owner Name �� Facility ID#(if applicable) ft. ft.'7 i''' ,4 ///G; QX £ ()NH I ft ft 7e 'k.,,G f
Physical Address,City,and-LLip 21.REMARKS - -
/.',1Ae/ah► 0y--622--61 SS OCT 1 : 2023
County Parcel Identification No.(PIN) IrtfC1 r„F,,.;-, ,,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certifi 'on: 1
(if wall field,ono 1st/long is sufficient) fillipp,
3zi! 8a/ z./ N 10.e/g5/ C) w 9-5- 2.3
� Si of C Ted Well Contractor„ Date
6.Is(are)the well(s): lllP nanent or ❑Temporary By signing this arm.I hereby certify'that the well(s)was(were)constructed in accordance
with ISA NCA 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 17No copy of this re rd has been provided to the well owner.
If this is a repair fill out known well construction information and explain the nature of the 23.Site diagram or additional well details:
repair under#21 remarks section or on the back of this form.
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 24.Submittal Instructions:
submit one form. I
9.Total well depth below land surface: 3 Vo (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'and 2Q100') construction to the following:
10.Static water level below top of casing: 30 (It) Division of Water Quality,Information Processing Unit,
1617 Mail Service,Center,Raleigh,NC 27699-1617
If water level is above casing,use/"+" t
11.Borehole diameter: l" /// (in 2 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
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12.Well construction method: Ar; fi cie2 construction to the following:
(Le.auger,rotary,cable,direct push,etc.) Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service(CIenter,Raleigh,NC 27699-1636
Method of test: l'h.c.".., 24c.For Water Supply&Geoth`ermal Wells: In addition to sending the form to
13a.Yield(gpm) the address(es) above, also submit one copy of this form within 30 days of
/� completion of well consrction I o the county health department of the county
13b.Disinfection type: #�//i Amonnt: where constructed.
Form GW-I
North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013