GW1--06904_Well Construction - GW1_20231030

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
1.W Contractor Innfformmaatioon:�C
iv-L,, - Jt�ss�`t( V2 14.WATER ZONES
FROM TO(We/ll/Con�tractorName /`� ft. i ,7�.�•t. DESCRIPTION�
`�( `-'( (mil`( �-�, h ft. O`CJft.
NC Well Contractor Certification Number '.IS:OUTER:CASING(for r oItgiased wells)OR LINER(lisp !liable) ' -
-t� FROM //TWO 11 DIAMETER THICKNESS MATERIAL
MATERIAL
Ql( l l j_C X(�S Inc C v ft. l v ft- C i' In. SO i2 9' PVC
Company Name ✓ �'
• 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 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.
Water Supply Well: FROM TO DIAMETER SLOT SiZE THICKNESS MATERIAL
*Agricultural I°_Mun' ipal/Public 0 ft' ft. in.
*.Geothermal(Heating/Cooling Supply) no, •esidential Water Supply(single) ft. ft. in.
NI Industrial/Commercial OIResidential Water Supply(shared) 18.GROUT-
!Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. /0 U ft. (o`4 "'_C1 f)(7.04 co/6s.
*i Monitoring 'ecovery ft. / ft. ' //(L
Injection Well:
It. ft.
®i Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
aIAquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
*iAquifer Test °Stormwater Drainage ft. ft.
j!Experimental Technology °Subsidence Control ft. ft. L._.__ 7
NI Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
a'Geothermal(Heating/Cooling Return) [Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rocktype,grain size,etc.)
// ft. ft.
4.Date Well(s)Completed: y��/a3'Well 1D# qq I 13(p ft- ft.
Sa.Well
nLocation:i� ft. ft.
° FUnit Nouse ft. ft. v ._ .r y �V ,� € }I a
Facility/Owner ame Facility ID#(if applicable)
ft. ft.
, o 1-11 U PO 120u,tcivt-r UC Jr1r1c9 ft. ft. OCT 3 0 nu23
Physical Address,City,and Zip ft. ft. Ir f F..'I) Pr,,,... ie.c+i?'al i lr•:.
r 1(Sr 11®r l 21.REMARKS D. ;:;:'f;
County Parcel Identification No.(PIN) 1_, '�,,,i/# ('teker '4.,;r c- /.S ' ',
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: C UI,W�
(if well field,one latt/llong is sufficient), /, / 22.Certification: J 1 10. 3 ! G IN-- '2. -, �i h"( WAz, - ---,,,,,,s,-C Iniczia 3
the wells rmanent or Tern o e of Certified Well Contractor Date
6.Is(are) () Py
�� By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ud"' or cilNo 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.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 1i GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: a ceo (It) 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: ,
10.Static water level below top of casing: so./ (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing, G use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter 6--,-f (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: '
(i.e.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
/^ t
13a.Yield(gpm) (1 Method of test 24c.For Water Supply&Injection Wells: In addition to sending the form to
II ++ the address(es) above, also submit one copy of this form within 30 days of
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13b.Disinfection type: I 'f�-1--f f Amount 64 e.4 completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resource Revised 2-22-2016