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Home My WebLink AboutGW1--06891_Well Construction - GW1_20231030 IF1 WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: Print Form 1.Well Contractor Information: ph, /v b)J(1fl3 Well Contractor Name FROM TO DESCRIPTION ` 63 T 9115� ft air ft NC Well Contractor Certification Number V ft- 3�� R I 4` �^� ��D^ ,n �Q�� 'IS.OUTER CASING(for multi-cased wells)OR LINER(Hap Ucable) - t 1 /1 W/ t t, FROM TO JL7R [TWCK4ESS MATERIAL t in. cr�/ PV G Comp are t/ 13 �/ Rw�am '16.INNER CASING OR TUBING(geotheiwal closed-loop).;'. 2.Well Construction Permit#: V R 30(Q/ J 6 FROM TO DIAMETER THICKNESS MATERIAL List all applicable well construction permits(Le.(IIC,County,State,Variance,etc.) ft. ft in. 3.Well Use(check well use): ft ft. in. Water Supply Well: 17:SCREEN . Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL g DMunicipal/Public ft ft in. Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in. Industrial/Commercial OResidential Water Supply(shared) -18.GROUT "'r - • ..- .:..- Irrigation FROM TO MATERIALp EMPLACEMENT METHOD&AMOUNT Non-Water Supply Weill-- 0 " 0 ft i to& !I POI'! Monitoring DRecovery ft. ft Injection Well: Aquifer Recharge ft f. 4 °GroundwaterRemediation Aquifer Storage and Recovery ga]i� Barrier .19.SAND/GRAVEL PACK(If applicable) . .: • .- Y_ M ty FROM TO MATERIAL EMPLACEMENT METHOD Aquifer Test 0 Stormwater Drainage ft ft Experimental Technology LDSubsidence Control ft. ft Geothermal(Closed Loop) QlTracer - 20.-DRILLING'LOG(attach additional sheets if necessary) - 1 -- - FROM TO DESCRIPTION(color,hardness,!Wrack Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft ft D t type,cram size,etc.) S 1S�r�3 t� P3c� n, i / Sand /Zoe-K 4.Date Well(s)Completed: Well ID# 1 ft ya5.ft �/G.e /�/ci f�e 5aa..Well Location: ft. ft ��//J l� (/�-vine r. i.4seM ltuda1e jro ft. ft. Facility/Owner Name Facility ID#(if applicable) ft ft y 1 € 1 q'"':- o,N....i vi 1''i :) 1 Y? Le,(ite ti)4li ' A'i� ft. ft OCT C �v Physical Address,City,and Zip L��1 c,Q /� ft. ft 20Z3 6CJ/'� ! 1✓ 11 63(43� 21:REMARKS: ' .. • lltiJ:,c. *.,,-,.��.. County Parcel Identification No.(PIN) •5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field,one lat/long is sufficient) 22.Certification: I p N W `]� 13l -/O-0�3 6.Is(are)the weU er(s) manent -or [Temporary Signature of Certified W Contractor Date �l —^ By signing this form,I hereby certify that the well(s)was(were)constructed in accordance ['N 7.Is this a repair to an existing well: DYes or o with 1SA NCAC 02C.0100 or 1SA 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: You may use the back of this page to provide additional well site details or well 8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same 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 if different(example-3Qa 200'and 2t1009 Y p construction to the following: I , 10.Static water level below top of casing: If water level is above casing use"+ (ft.) Division of Water Resources,Information Processing Unit, 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 12.Well construction method: above,also submit one copy of this form within 30 days of completion of well (ie.auger,rotary,cable,direct push,etc.) construction to the following: FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699-1636 13a.Yield(gpm) Method of test 24c.For Water Supply&Injection Wells: In addition to sending the form to 7_Id,�� !- the address(es) above, also submit one copy of this form within 30 days of 13b.Disinfection e:( J!I Amount: It 7.C'Z- completion of well construction to the county health department of the county where constructed. ! 1 Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources, Revised 2-22-2016