GW1--06558_Well Construction - GW1_20231006

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
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• T. I SO tlatt,A
14.WATER ZONES I ,
Well Contractor Name • FROM TO DESCRIPTION
ft R ' '
3so7
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NC Well Cotrtractar Certification Number I
fl ,,+. ,` IS.OUTER CASING(for wed)OR I.R+1113I1 O )•
atAtiY'M Mettifil ©tt tl4W 4--` 0bi Se vttce 1 ,W4 FROM ft. TO
a DIMMER. THICKNESS lI MATERIAL
in.
Company Name 16.INNER CASING OR TUBING(geothermal dosat.lnnp)
2.Well Construction Permit#: WWI I 0 30 1513 • FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIIC,Counn•,State.Variance,etc.) / 3O it 0 fl- 2 ta. SG17.444 1141e,
3.Well Use(check well use): ft R. in-
Water Supply Well: 17.SCREEN
I-� cultural FROM TO DIAMETER .SLOT SIZE THICKNESS MATERIAL
QA€ri f MunicipalPublic 140 f 30 ft 2 in 0.0 t s.t40 NC
QGeothermal(Heating/Cooling Supply) nResidential Water Supply(single)
ft R. in,
QIndustrial/Commercial QResidential Water Supply(shared) 1&GROUT
f Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
NMWater Supply Well: i., ZS ft. 24 R- Mein'. __twit
onitoring QRecovery ft — ft-- — —
Injection Well:
QAquifer Recharge 0Groundwater Remediation it ft.
19.SAND/GRAVEL PACK ft/applies/de)
Aquifer Storage and Recovery Salinity Bather FROM - TO MATERIAL EMPLACEMENT METHOD
QAquiferTest QStormwater Drainage I4O ft Zg II- .)!F Z Men 124 OR.
QExperimental Technology QSubsidence Control . ft. IL
•
[Geothermal(Closed Loop) QTracer 20.DRILLING LOG(attach adddtiaattia tsar esaatg)
FROM TO DESCRIPTION(oiler.haadre,seakeek
Geothermal(Heating/Cooling Return) nOther(explain under'#21 Remarks) rt. a. t grab,size,ems)
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4.Date Well(s)Completed: Zz^v?3 Well II)# �) 4" TZ ft R
5a.Well Location: ft ft. �' s :!_ J "
yam) . a
SVt,p?amrr (evil— ..
Factlity/Own ft @ �. ". •r .a .b s,,
s Facility Mil(if applicable) (i.— --- __...__'--OC-r -
0--r 2G23
TA}. of G arpit e. &vet,4- elm Si-. Mccrs►,Nille ft ft. inf;t- `,)^:1 r.)r ,.- -
Physical Address,City,and Zip P� ft • ft i rj'•v C:1`,:�a i'
V In 1 21.REMARKS
County Parcel Identification No(PIN) ,
5b.Latitude and longitude is degrees/minutes/seconds or decimal degrees:
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(if well field,one latflong is sufficient) • 22.Certification: , I
N W i'11 9-24—Z3
6.ts(are)the well(s)ijPermanent or �Tempor•ary Signature ofCerii red Well Contractor Date
8v signing this form,I hereby ceri,:rhat the well(s)was(were)constricted in accordance
7.Is this a repair to as existing well: Dyes or Er No with ISA.NOAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
/f this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner. .
repair under`II remarks section or on the back of this form. -
23.Site diagram or additional well details:
. 8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well •
construction,only}fiW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if nereccaty.
drilled: VAN
0 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Ze 1O (ft') 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3C3a 200'and 2@a 100') construction to the following:
10.Static water level below top of casing: _(ft)(ft.) Division of Water Resources,Information Processing Unit,
II-water level is above casing,use'• t 1617 Mail Service,Center,Rakigh,NC 27699-1617
11.Borehole diameter: k (in.) ' I '
24b.For Injection Wells: In addition to sending the form to the address in 24a
i ?Awl above,also submit one copy of'this form within 30 days of completion of well
12.Well construction method: Ark 1�►w N construction to the follo '
(i e.auger,rotary,cable,direct push.etc.) JJ wing: j
Division of Water Resources,Undergrw®d Injectlon,Control Program,
FOR Wit-TER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) Method of test: 24e.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13h.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-t North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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