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Home My WebLink AboutGW1--06887_Well Construction - GW1_20231030 ;Pint FOrm- WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only: 1.Well Contractor Information: Lhr s-10 her 13vll dns Well Contractor Name FROM TO DESCRIPTION g3 i a A1/fl ft. aopft . ft. ft. NC Well Contractor Certification Number /1 //"�] t/� M��/� -15.OUTER CASING'(for multi-eaasee�'d wells)OR-LINER tR LLIINER)(if lip &ablle) '_ ' C. CA J /, fal.. 1 �&!( Go/ t/./e l� .FROM Z / /T ER .THICKNESS MATERIAL L . - t 0 ft. (J ft. t in. Comp ame /n/J ^,j}�^� Q -:16:INNER CASING.OR TUBING.(geothermal closediloop):.- _ 2.Well Construction Permit#: /1W . lYG) )-sDDaa U 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 in. 17.SCREEN•, .. Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS• MATERIAL Agricultural 1�IMunicipal/Public ft. ft. in. Geothermal(Heating/Cooling Supply) MI'esidential Water Supply(single) ft. ft. in. ' Industrial/Commercial OIResidential Water Supply(shared)- IS GROUT' = Irrigation FROM TO MATERIAL - EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: ft' [t /9/6 i? ., P i' , T Monitoring Dr�Recove _- !C! ("e'`1' - ' LJ� rY -- -ft ft. Injection Well: ft. ft Aquifer Recharge 111 Groundwater Remediation 19:SAND/GRAVEL PACK(lf applicable) = - Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD Aquifer Test OIStormwater Drainage ft ft Experimental Technology OSubsidence Control ft. ft. Geothermal(Closed Loop) (Tracer _20.DRILLING LOG(attach"additioual'sheets if necessary) Geothermal(Heating/Cooling Return) f lOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness sot0rnck type araln size eta) 0ftao " ged G/ .. 4.Date Well(s)Completed: 6'5--D3 Well ID# 30 ft `7(. ft 5a.Well Location: -7t ft. 325 ft. l 'e i!raft,¢e, t�p�t.JG,Pp� 5/Yf j5) ft. it. V Facility/Owner Name Facility ID#(if applicable) ft ft. y• ^�- __,- r7,---:M1� 305 Pcnnatl e in1. P�n46l-e ft. ft. `e.'5.,..i YY F ..r� Physical Address,City,and Zip ft. ft. Sp OCT 3 , ?�� fff r 5963005-89063 21:REMARKS'. - ., into, County Parcel Identification No.(PIN) �7 >. 1 Ur:). 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field,one lat/long is sufficient) 22.Certification: i I N W 8/4, 6-5-D3 6.Is(are)the well(s) anent or °Temporary Signature of Certified We Contractor Date By signing this form,I hereby certifr that the well(s)was(were)constructed in accordance 7.Is this a repair to an existing well: °Yes or To with 1SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a If this is a repair,Jill 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: 3 a?5 (ft) 24a.For All Wells: Submit this form within 30 days of completion of well For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following: I i LiO I 10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit, IJrvater level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617 11.Borehole diameter: (in-) 24b.For Infection 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: (Le.auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground Injection Control Program, FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 /PLI.� 13a.Yield(gpm) f Method of test: 24c.For Water Supply&iniectil n Wells: In addition to sending the form to HI �' • the address(es) above, also submit one copy of this form within 30 days of 13b.Disinfection type: I �(T Amount: 512Z— completion of well construction to the county health department of the county i where constructed. Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ' Revised 2-22-2016