GW1--06947_Well Construction - GW1_20231027

WELL CONSTRUCTION RECORD(GW-1). For Internal Use Only:
1.Well Contra rInformation: ,
A ,4 �, 7 1:WATER ZONES 1
WeIICotrttaaorName FROM TO DFSCR�rION
ft 55 oft.
oi- A f. R i
NC Well Contrauor i cation Number 45.OUTERCASING(for wells)OR LINER(if • )
r FROM TO DIAMETER THiCKN SS MATERIAL
Company Name ft ere) ft. b' in. Pie .
1�1 9 .16'1NN€RCASING.OLTUBl'NG.(geaffiamatclosed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC. State,Variance.etc.) ft. A
! ft. in.
3.Well Use(cheek well use): ft '0.4 m'
Water SupplyWell: 17::SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agriculttual OM lic o f. ft. in.
Geothermal(Heating/Cooling Supply) idential Water Supply(single) !1 en in. .
Industrial/Commercial Residential Water Supply(shared) ._/// VV ..(` ... •
.
IIrigatiOD. FROM TO MATERIAL EMPLATIENT METRO &AMOUNT
Non-Water Supply Well: ft. c)v f' t?©tl(2(4 v 0 doPKV A H.eleo
Monitoring -- - ---ORecovery ft. ft.
Injection Well:
Aquifer Recharge Dcnoundwater Remediation
19..SAND/GRAVELTACHCsfappGcable),
Aquifer Storage and Recovery °Salinity Barrier FROM MO MATERIAL EMPLACEMENT METHOD
Aquifer Test' DStormwater Drainage ft ^
Experimental Technology Subsidence Control Ao d RI
Geothermal(Closed Loop) Tracer ~:2o:DRILI.ING.I.00..(asmdiadditianaI3Leetei ry)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM T O Dot tAx( �.,�as�air«rc cue grain etc.)
r
4.Date Well(s)Completed:/a'/r,�7/o(T Well ID# ��f. VOOft• :/ " �l
5a.�` ell Location: // _f. ftI
Facility/Owner Name ��// Facility ID#(if applicable) ft. ft. •"'0. P., u ism 4. .1,,,)
21�/ /7`� .4 SL./s "./ ft ft. fCT 2 7 2023
ft.
Physical Adams City,and Zip(7' ..... ..:2LREMARI{S' Iniv,r . 1
T . !4r QL,,.ri lI rA
r DW'.r_I
County Parcel Idenafcation No.(PIN) ,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ` y
(if well field,one laNlongis sufficient) 22.Certif"ication:
° / .‘'J-f
6.Is(are)the well(s) Permanent or °Temporary Signature of Certified Well Contractor /Dace
By signing this form,I hereby terrify that the wells)was(were)constructed in accordance
7.Is this a repair to'sus existing well: DYes or No - with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a.
If this is a repay,fill out,brown well construction information and esplain the nature of the Copy of this record has been provided to the well owner.
repair under 1121 remark sectioir 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 nerwssary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / C) (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2( 100') construction to the following:
10.Static water level below top of casing: ' (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+' � - 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in) 24b.For Injection Wells: InI addition to sending the form to the address in 24a
12.Well construction method: TC'Dar
above,also submit one copy of this form within 30 days of completion of well
(i.e.alga,rotary,cable,direct push,etc.) construction to the following:
y
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) / Method of test: //7 4' 24c.For Water Supply&Injection Wells: In addition to sending the form to
'�jj the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: fr/ ft Amount: /D Z completion of well construction to the county health department of the county
where constructed. I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016