GW1--06905_Well Construction - GW1_20231030

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1. ell Contractor Information:
l
Ii , ‘ 8 • 14:WATER�ZONES -:' . , ..
FROM TO DESCRIPTION
Well Contractor Name
1414 6
q-C )ozot. J ) ft. so-,8e '
ft. ft.
NC WellContractorr Certification Number ,,/� Is:OIUTERCASING'(for multi.eased wells).OR LINER'(if ap licable) ,
l �Y t A/1 zQ 1Y ds I.V iC FROM
�/ ft. TO /7 ft. DIAMETER in. �C THICKNESS MATERIAL
Name
l/ V i,kb9 . p r/6
Company am
"46.INNER CASING OR TUBIP (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. I in.
3.Well Use(check well use): ft. ft. i, in.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
*Agricultural *'Municipal/Public 0 ft. ft. in.
®Geothermal(Heating/Cooling Supply) ! 1 Residential Water Supply(single) ft. ft. in.
MiIndustrial/Commercial DResidential Water Supply(shared) ts.GROUT_
:, i Irrigation FROM TO MATERIAL EMPLACEMENT ETHOD&AMOUNT
Non-Water Supply Well: D ft. u j) ft. porg,�qCi ,E ,v.4 ,2' o I�6.,„i Monitoring g'Recovery ft. I ft. �
Injection Well:
ft. ft.
NliAquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
)1 i Aquifer Storage and Recovery 0Salinity Barrier FROM TO "MATERIAL EMPLACEMENT METHOD
*'Aquifer Test 0 Stormwater Drainage ft. ft.
[Experimental Technology IDSubsidence Control ,ft. ft. ( 1
®i Geothermal(Closed Loop) Tracer 20.DRILLINGLOG(attach additional sheets if necessary) • -
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
(r Geothermal(Heating/Cooling Return)
Other(explain under
#21 Remarks) ft. ft.
(
4.Date Well(s)Completed: "1/t7-'�/'/(Well lD# t'-ta' Ii 30 R. B.
Sa.Well Location: ft. ft. S
Richard) lt"l 1 rl r 1 ft. ft. . . ._.1.. . n...-I u' ',,...1.”..
Facility/Owner Name Facility ID#(if applicable) �/ ft. ft. 0 L i 3 0 2023
l�Sl(i'1 (�)riq S S�v CJ�rP K rb OC,Alc'fif ft. ft. 1 ir+.,`•�r,-r.~Y,..�,..n P,-.-, �•;
Physical Address, y,and Zip ft. ft. D;:,�n G
P-Li.7cin -21.REMARKS p / {�
County Parcel Identification No.(PIN) !h i r' "la I,. � c� - r r-D,` L,r „/
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ` elk Po')
rf well field,one lat/long is sufficient)
h 22.Certification:
.yv �5o�,1 N — Q -/5 `J W
6.Is(are)the well(s) ent or Temporary Signa a of Certified Well Contractor 1 Date
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: 10, es or ONo with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out'mown 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 Ito 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: I SUBMITTAL INSTRUCTIONS i
9.Total well depth below land surface: (9-(00 (ft.) 24a.For All Wells: Submit this Iform 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: 9-t (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: (., `1 (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: l construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) l
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 0 Method of test: f)(/IVKQ 24c.For Water Supply&Iniecti I Wells: In addition to sending the form to
+� I�P� the paddress(es) above, also submit'one copy of this form within 30 days of
13b.Disinfection type: Amount: A (, completion of well construction to the countyhealth department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016