GW1--06885_Well Construction - GW1_20231030

! Riint Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: i ___r
1.Well Contractor Information:
Ph r(t"f) 0 v i 11 0�s 14 WATERZUNES __; = i
Well Contractor Na a FROM TO DESCRIPTION
LI5 3 q •;,:x4 ft. a-7o ft
15::QUTER"CASING for-multhcased.i
ft ft.
NC Well Contractor Certification Number .
/� //�)/��.y�9,�1 /J / 1/'�1 �/l � - (for: vi%e11s)/OR 1LIN^ER(flap Ilea(��b7le)�/f._ ._.....•
(`a�' 1 CJ( t/lit// 1 �Ti'` (s V��"'+� MATERIAL
/7 ft.FROM Ti.'7 ft. /_ t i in. SOr I THICKNESSO DIAMETER / i/
company-Mime { ' G '•:116-INNER.CASININIG_OR'TUBING:(geoth'e inalclosed-loop);
2.Well Construction Permit#: 1 1 .b. ✓1 V u O a i ` FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. / in.
3.Well Use(check well use): ft ft 1 in
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural jMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) H. n. in.
Industrial/Commercial fesidential Water Supply(shared) 18:GROUT-_ >, ;
:-Irrigation FROM TO ,MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water-Supply_Well:_ -— — ft a� R (�G'11�+�'1r fPi J Qtl/— — — —
Monitoring 4 Recovery ft ft.
Injection Well:
ft. ft.
Aquifer Recharge l�Groundwater Remediation
19.SAND/GRAVEL PACK`(if applicable) # ,
Aquifer Storage and Recovery I Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology
ISubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer :20.DRILLING`LOG.Attack additioaaIsheets-ifnecess`a ' -'
Geothermal(Heating/Cooling Return) �IOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soli/rock type,grain size,etc.)
p n " -70 ft .5 7( L
4.Date Well(s)Completed:454 O".D9 Well ID# 70 IL 3 . ft. blue &rant T e-
5a.Well Location: ft ft
d ► ►do. 1-1'611n et ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft ft 1 Y.;^-`i R'--`• ''
1bD 5'Iowr► R 3 0nbson NC- ft. ft. - ' ��-' ._. ,v: �1 d
Physical Address,City,and Zip ft ft o C T 3 0 2023
6Urr . f93'00- 7 jig i 21.REMARKS: - I ;_ ".
County Parcel Identification No.(PIN) 1 t i•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
•
(if well field,one lat/long is sufficient) 22.Certification:
N W rtizapw
8/S-a3
6.Is(are)the well(s) (Permanent or °Temporary Signature of Certified Well ontracror Date
By signing this form,I hereby certt that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or To with ISA NCAC 02C.0100 or ISA 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.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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: — SUBMITTAL INSTRUCTIONS' '
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 ifdifjerent(example-3 r@200'and 2Q100) construction to the following: R
10.Static water level below top of casing: -7 6- (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following: r '
(i.c.auger,rotary,cable,direct push,etc.) y
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I
13a.Yield(gpm) f a Method of test - _- 24c.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
13b.Disinfection type: t A JD/'i/le. Amount /gDZ completion of well construction Ito i the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources+ Revised 2-22-2016