GW1--06497_Well Construction - GW1_20231013

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells •
I
1.Well Contractor Information:
v Eli del `ac tPr/ /3t1 .i I4.WATER ZONES . I . .
/ �/ C FROM TO DESCRIPTION
Well Contractor Na a ft. ft. • Jy/j /13 Q
116 G IL ft: qss �l
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if ap licable) '
FROM TO_ � DIAMETER THICKNESS MATERIAL22. L; n7 cd/' 2ve1/ `t�i,"L!�'6:y ,2///c -/ IL 15 '' I (S /Yr ,,.2 S Ind c
Company Name 16.INNER CASING ORTUBING'(geothermal closed-loop)
' a FROM TODIAMETERTHICKNESS MATERIAL
Z.Well Construction Permit#: 3 ft. ft. I ' in,
List all applicable well construction permits(i e.Count;State,Variance,etc.)
ft. ft ' in.
3.Well Use(check well use): r
17.SCREEN - - -
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. I in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) iitldential Water Supply(single) ft. ft. :in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation t ,
�0 e^'p1�/1 t �[9 tt r e c/
Non-Water Supply Well: ft. f
ft. ft.
❑Monitoring ❑Recovery _
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)• .. - '
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft. ,•
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attacii"additional sheets if necessary), "
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soit/rock
❑Geothermal(Heating/Cooling Return) (explain Remarks) O m 7 0 ft- I k ed C i..Y type,grain Size,etc.)
(Heatin Caolin C� �/❑Other e2x lain under#21 �
4.Date Well(s)Completed: ! -' // -.23 'q,7 ft' Gam, -5
5 ' /OCR V 44.-e aeu
5.Well Location: ft
'�ebat-c,.h e„ ft. it.
Facility/Owner Name Facility ID#(if applicable) ft. ft
6 00[d pJ h LC C-EeS rt
7& L A/ . tt. "�e ^'
rN . k.:., Y ��
Physical Address,City,and Zip "
21.REMARKS
union as-b 78- 0311 DCI I 2023
County Parcel Identification No.(PIN) In iC_7.,`3 7i a,.--.:.-
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: G'`'`1�"!,-a,z,,41 a-it;
(if well field,one lat/long is sufficient)
36/9 6d "7o23 N $d, '"1ol5ci W - 9- 6/
5Ygn of red Well Contractor 1 Date
6.Is(are)the well(s): tiRfecmanent or ❑Temporary
By signing this form,I hereby certify Illicit the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Elt copy of this record has been provided toithe well owner.
If this is a repair,Jill 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: - / construction details. You may also attach additional pages if necessary.
For multiple injection or non-Ivater supply wells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: g Q 0 (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: 3 S' (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: /O//g (in.) 24b.For Infection Welis: In addirio'h 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: /D!1_�t V 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 Mall Service Center,Raleigh,NC 27699-1636
n A h 24c.For Water Supply&Geothe I al Wells: In addition to sending the form to
13a.Yield(gpm) (� Method of test: f the address(es) above, also submit I one copy of this form within 30 days of
y completion of well construction to the county health department of the county
13b.Disinfection type: ! # Amount: 3 p MILS where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013