GW1--07143_Well Construction - GW1_20231101

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: •
1414WATLRIZONES1W:; ,.,, surf Y t .qht . 0 T„x, z,„ z,.:
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
15 9 5 -A ft. ft. I
NC Well Contractor Certification Number 13 071RiI:R C")1S11VOi{fo imtiitgr etuifCIU)ARtISINLrII+'(if?i ii ]li hers"t'etA4
FROM TO DIAMETER THICKNESS MATERIAL
�-i/�s 'AAAartart d l�vv�l� I ft. q,L ft. �`,I2,5 tn. Spti2I J7V
Company Nark 166r R� Gd0 1NO`'�ebthdrmpllcloit9laou rr'ss?�iFp %` rr t 0,
�A�,q :lIV1YE i✓�>l�. RUB ,{ Pr
2.Well Construction Permit#:,) V"�C.3 13 I 1 1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft. in.
• ft. ft. In.
3.Well Use(check well use):
3y14."ss$.C:RFTIIIMt:Wis:ggelha??r..(E:ge,,,-:stWTW3- IO1a0U ,Wii.OME.1_`..
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. !in.
i
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. I he.
Industrial/Commercial OResidential Water Supply(shared) ,1'8'"OROI)3!t 10,,V'w•7 t;fir':;,,i .,,l; "'-Ati .,Yjr` a;V^u"l'.: `
Irrigation FROM TO MATERIAL EMPLA METHOD&AMOUNT
Non-Water Supply Well: 0ft* + ft (3 l f-e'"1-d t t
Monitoring ['Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge OGroundwater Remediation ;,1495?SAND/GRAAYELIFA' :W's iPlicsble)t Ohi g t -=:',A ; 1-'gr s:iMK14
Aquifer Storage and Recovery ' OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test s`. OStormwater Drainage ft. ft.
Experimental Technology •', ‘.• OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer • '201 DRlki sPrOMO.`Gi(attach addi(filifi idAfilfih"ecelt Y) ; s `: d xz:.? ;;
FROM TO DESCRIPTION(calor,hardness,sallfrach type,grain size,etc.)
Geothermal(Heating/Cooling Return) QOther(explain under#21 Remarks) © ft. ft. C)ky
4.Date Well(s)Completed:I 2'y 23 Well ID# et3 tt' X,I15 ft. &rr vtlt tt
ft. ft. ,
5a.Well Location:
okc r).e,s Alloy pe,
ft. ft. , :;:."'U, ,,, _
Facilipty�/Gwnerl�Name ,� / Facility ID#(if applicable) ft. ft. '4-a,'I"'• to lc._3 1
V� D FOCI— WDt I I 1Q , ft.ft. ft. NOV «) X �(�C�
Physical Address,City,and Zip I^
M `ZimEmAR`I s§ v;!r L.,,, 4 . .i;�`r p ar!.: ., 1 :f , �',,
County Parcel Identification No.(PIN) - ,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: • •
(if well field,one lot/long is sufficient) 22.Certification:
5 ,Cz735 N gI,q3167 w c i1-� j''� 1P-3f'J`
6.Is(are)the well(s) Permanent or OTemporary
Signature of Certified Well Contmotor 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: OYes or gANo with ISA NCAC 02C.0100 or ISA 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 GeoprobeiDPT 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: �'
r` (ft.) 24a. For All Wells: Submit ids 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: q 0 (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: G (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: 19Ov 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
C {t' 24c.For Water Supply&Inlection Wells: In addition to sending the form to
13a.Yield(gpm) .I Method of test:
(�1�p�,r the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:V►1Ut"1 NA, Amount: 9�' completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resourca s Revised 2-22-2016