GW1--07208_Well Construction - GW1_20231108

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: .
1.Well Contractor Information:
7 O 11
P INI 9 I`(1 p O v I l i f L S 14.WATER ZONES - . . - -
FROM TO DESCRIPTION
Well Contractor Name N/n ft '100 ft. j
YS3 � ft. ft. i ;
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
ZG` � �/ /v y� FROM
ft TO
ft. DIAMETER
I THICKNESS MATERIAL
\M 0 r101 Owe) e /-1,4,4 j
Company ame
2.Well Construction Permit#: in. -.
3 9 L/ 16.INNER CASING OR TUBING,(geothermal closed-loop)
FROM - TO DIAMETER THICKNESS MATERIAL --
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft• 7 0 ft• %t0,a S. in• 5 1c 2/ pvc.
•
3.Well Use(check well use): ft. ft. in. O /
Water Supply Well: 17.SCREEN
_FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL _
AgriculturalMunicipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) ! Residential Water Supply(sin )
le --- - --
g in.
Industrial/Commercial Residential Water Supply(shared) ft ft 18:GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water_Supply Well: �_ ft. ft. PO tie
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
' Aquifer Test
Injection
Drainage ft.
Experimental Technology Subsidence Control ft. ft.
0 Geothermal(Closed Loop) OlTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) QlOther(explain under#21 Remarks) FROM TO DE CRIPTION(color,hardness soil/rock type grata size etc.)
0-�1 ^ D ft. -a0 ft ej 6/604
4.Date Well t s)Completed: �17-p�.3 Well ID# -- -- 3 O ft /j 5. ft• S4.n d Roe*
5a.Well Location: (O S ft. ya S tt. 6/tie /t4A/T-�.='� -
(ha`/0/4e Sea f - ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft ft. N O V J 8 2023
51qo NG egg l/cJ`( �i lA1ZS�T,��� ft. ft. , ,._77'.::-.:,' !":,
Physicalss
Address,City,and Zip f 1. t ft j i ,._
[',,C: ;ja,
S/0 L e ,21.REMARKS
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: 1
1
N W p �8G to- 7- D3
6.Is(are)the well(s)+Permanent or L_PTemporary Signature of Certified ell Contractor Date
By signing this form,I hereby certifii that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or Vo with 1SA 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
�f
9.Total well depth below land surface: (R•) 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(4100') construction to the following: 1
i
10.Static water level below top of casing: (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: (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: 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
13a.Yield(gpm) 3/4 Method of test: 24c.For Water Supply&Injectiou Wells: In addition to sending the form to
i•'t the address(es) above, also submit)one copy of this form within 30 days of
13b.Disinfection type: Hi 14 Amount: ��V Q Z. 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 Resources I Revised 2-22-2016