GW1--06798_Well Construction - GW1_20231023

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
1.Well, Contractor Information:
l\, � tkI 1\S 'v'I4.:WATLRZONFS,:... y, :
FROM TO DESCRIPTION
'
Well Contractor Name 6 6" rt 6 S ft. I 1
LOC-Lt. --� f,Y►4-P E i .c Rr\kit t,q 1'so ft. aoo ft. 9 ,
NC Well Contractor Certification Number �1 "IS::OUTER'QASING(for:intiltiiensc8 well!)OR'L•7NER',(jf up"licuble)`::7••;':;,:f.•.;;;;;�r.
-)O q� pi •FROM l TO /DIAMETER' SDK
M
rATE
lRIAL
Company Name CJ (t ft. I, 5
ft. 1 IO.t/t(i l`I J DK IX.( PVC
C
:'•16:INNER•CASSINMODMIBING:(Reotliciiiitalosed-loopr..W._: -
7/��
2.Well Construction Permit#: l I V 4 el I FROM TO DIAMETER THICKNESS MATERIAL
In.
.'.
List all applicable well construction permits(Le.County,Stale,Parlance,etc.) R. ft. •
ft. ft. irr
3.Well Use(check well use):
Water Supply Well: FROM TO • DIAMETER' SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M ' ipal/Public ft. ft. Mtn
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. [L /! is
l'19;:GROUTI :t`
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Irrigation FROM ••TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 3 a it. S2n i-14,n ae- ?urn e.c�: i1 S 4q�.
OMonitoring ❑Recovery fr. ft 1 rr landAed Injection Well: ft. R
❑Aquifer Recharge ❑GroundwaterRemediation 19 SAND/GRAVET:PPACK(ifapplicablc)
I '
❑Aquifer Storage and Recovery ❑Salinity Barrier
MATERIAL EMPLACEMENT METHOD
FROM 'TO
❑Aquifer Test ❑S ft.
tormwater Drainage
❑Experimental Technology ❑Subsidence Control ft. tr.
OGeothermal(Closed Loop) ❑Tracer 20:'DRILLING.I OG•(hitticli ufldiddtial'abcots'ifti'ecessary)
,.):.
OGeothermal(Heating/Cooling Return) ❑Other(explain under 1121 Remarks) FROM TO DESCRIPTION(eolmt hardness,sa int&type.grain sic,cm)
p 0 tr. 30 ft- C O,.I.
4.Date Well(s)Completed: 3 - o -a0e 30 fr. S'a ft. J !d ROC K
Soli
it. 5 a it. CaS e..d
5.Well Location: .
' ° S a ft. '1 ra o ft.
e5;51 . Ka-c-1)4 GI. ?9 �DI. ��
Facility/Owner Name ft. ft. �- T .•
/6,/�/�� /� FocIliryIDO(ifapplicable) Y.•a-- � v--,
es
Physical Address,City,and Zip ft, ft 0 r T Y 702:1
5 CZ '21ItEMA R; :Vi,1 ?J:.1 }.:. .:
CountyIr1, It n?::2n ^�. N,T g Imo$,'Parcel Identification No.(PIN) 1 uvv!.Y J Jt.i
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: i
22.Certification: !
(if well field,one lat/long Is sufficient)
35° a!>'3 N w/o'ao W (7 1���1 ~/o d
_� mturc of Certified Well Contractor 1 6 '6.Is(are)the well(s): lincrnranent or ❑Temporary Data '
By signing this form,I hereby cent*that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or fdt�io with ISA NCAC 02C.0100 or ISANCAC 02C.0200 Well Construction Standards and that a
If •
this is a repair,fill out known well construction information and explain the stature of the copy ojthls record has beenprovided to die ii e1J owner.
repair under#21 remarks section or on the back of thtisfonas. 23.Site diagram or additional well details:
8.Number of wells constructed: tV 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: !
9.Total well depth below land surface: �� f (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths((dierent(example-3 00 and 2 100
� ' © ') construction to the following:
10.Static water level below top of casing: b t (ft.) Division of Water Quality,Information Processing Unit, '
//water level is above casing,use"+" c r 1617 Mall Service Center,Raleigh,NC 27699-1617 .
_
11.Borehole diameter: (P (in.) 24b.For Injection Wells; In addition Ito sending the form to the address in 24a
12.Well construction method: ," r'y above, also submit a copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following: 4 13.FOR WATER SUPPLY WE Division of Water Quality,Underground Injection Control Program,
I b L.LS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
• 13a.Yield(pm) Method of test: MR.— 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
---�� n the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 1 t�i) e, Amount: $ ,p�� completion of well construction to the;county health department of the county
j where constructed.
•
Form GW-1 North Carolina Department of Environment and Natural Resources.—Division of Water Quality
1 Revised Jan.2013
iI