GW1--06771_Well Construction - GW1_20231023

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY: I
1.Well Contractor Information: I
NC, ('sL F'Jllis
lar•WiitiER!ZONES.: 1 +i . .y t•.: t ,,;:. ,r.. _ n:;..
FROM TO DESCRIPTION
Well Contractor Name A 9/96 ft. 2 0 oft. f
ti 3 V — ,US ft. z(,/Q ft. /
t
NC Well Contractor Eertifi ion Number I
/ AS OUTER{CASING'(fmimultt se'd Nells)'ORMINEIgtfrip ]iCiac": 2
On US* mp f 1 e '/ t 1 1 t FROM ft.
J TO ft. ID 4.IAMETER in. I THICKNESS MATERIAL
C...)
Company Name 16.INNERCASING:ORTUBING(geotltermaTdlosed-loo *:,.,r.;_•;
.3sS�9 r9 FROM TO DIAMETER THICKNESS MATERIAL a.
2.Well Construction Permit#: ft. ft. In.
List all applicable well construction permits(i.e.County,State,Variance,eta)
ft. ft. in
3.Well Use(check well use): /
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Mum' al/Public ft. ft. ini
❑Geothermal(Heating/Cooling Supply) tdential Water Supply(single) ft. ft. `in:;
❑Industrial/Commercial OResidential Water Supply(shared) i18FGROUT...,, ;i t..a'.,,, ;,: „
❑hTlgatl0n FROM •• TO MATERIAL EMAACEMENT METHOD&AMOUNT
Nan-Water Supply Well: () it 30 ft 1L7e01..a µjd• 7S&AL'-
❑Monitoring ORecovery ft. ft. lS R 1 n�, II �'
Injection Well: ft. R. / I t"rp (_!f
❑Aquifer Recharge ❑Groundwater Remediation .19.SAND/GRAVEIIPACI(ifnppIicuble)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑A uifer Test ft. fr.
q ❑Stormwater Drainage
❑Experimental Technology ' ❑Subsidence Control ft. fr.
❑Geothermal(Closed Loop) ❑Tracer ;20>DRILLING.1OG'(att,icli adilitianul'sbeete'if necessary) 1 r
Y
FROM TO DESCRIPTION(color,hardness,sollirock type,grain size,etc.) '•.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) o ft• /S ft. 05 O. L.
4.Date Well(s)Completed: ! „5-- 2' z 3 S ft ,��' fr. q D L; D fO GU
5.Well Location: L,a ft. ,� ft. Oj�,1�1_ 1 l\
"T'0 ft, 0744 rt. C�-/ToZCOD P---•,`
Facility/Owner.Naame f� Facility IDii(if applicable) T
s�o(o / �V C i d��jje f"� kd l�t r�ugc t . ft. ft. O C I ? t, 2023
Physical Address,City,and Zip
J ft ft.
STaft��y co 21 ttmAkit ., _:.;.r y:s C tr n r(? t u,R kIVA.4'.i'N'
County Parcel Identification No.(PIN)
fib.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: I
N W 4w W` 1 S 2 7
aue of ficd Well tractor i
Date-6.Is(are)the well(s): Remanent or ❑Temporary
By signing this form,I hereby certfy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: pyes or with 15A NCAC.02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If 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#21 remarks section or on the back of this form 23.Site diagram or additional well details:
8.Number of wells constructed: o��% You may use the back of this page to provide additional well site details or well
For,multiple injection or non-water supply wells ONLY with the same construction,you can construction details. You may also attach additional pages if necessary.
submit one form. 24.Submittal Instructions:
,2�0`
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'and 2Q100') construction to the following:
/`t
10.Static water level below top of casing: `14 (ft.) Division of Water Quality,Information Processing Unit, •
If water level is above casing sue'•+" r t 1617 Mail Service Center,Raleigh,NC 27699-1617 . ,
11-Borehole diameter: (in.) 24b.For Infection Wells: In addition ito sending the form to the address in 24a
12.Well construction method: s\
`'�b ry above, also submit a copy of this form within 30 days of completion of well
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 Mail Service Center,Raleigh,NC 27699-1636
Yieldt
13a. (gpm) IS'
Method of test: ��r 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: I A €15 Amount: L' a/J 704/0 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 Water i ual
Q n' Revised Jan.2013