GW1--07358_Well Construction - GW1_20231113

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor nformation:
O.R1,c C n e. C�ROP
v 19.WATER ZONES
DESCRIPTION
FROM
Well Contractor Name TO
a ft, ft.Oql CI
R ft A„ Q1 Je'eC-
NC Well Contractor Certifinon Number 15
a .0. 1 . n`1` -,.., •
FROM TO DIAMETER ITH11C-KNEES MATT�ERIAL
Company NameJ, 'R ` 0 ft ap ft. ate, in. 15 ck/lc, ` t)co
16.INNER CASING OR TUBING,(geothermal dosed-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: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural °Municipai/Public aD R 3 6 ft- `a in: I b I b sck L(0 P VC..
Geothermal(Heating/Cooling Supply) °Residential Water Supply(single) ft. ft. in.
Industrial/Commercial °Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: a ft' 15 ft. Co p c ,Q1AMe '
- Monitoring Recovery - - 15 ft. 1$ ft. t17ct"�., i ij e s e
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test °Stormwater Drainage I I ft. '65 ft, '6 3(I t4 T aerl'%le-
Experimental Technology °Subsidence Control ft ft.
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillroek type,grain size,etc.)
Q O fc I a'` ft' Cope..
4.Date Well(s)Completed: I(.. 6 -19-3 �M 3 Well ID# '1I"IF 7 IZ / 1 ft. OS ft- R'eek 1'A p.) a(D t* eJr4 SHNO'U
5a.Well Location: I3.5 35' ft. WhI-e TAN i�RM rj�{rgls.N.
j.-e v N A Rc4 a t l- ft. ft. J
Facility/Owner Name Facility IDS(if applicable) ft. ft.
1f2-RO U.0 -
. 15 C. l -'5grw 6v
le ,e. ft
Physical Address,City,and Zip /,1 t g, 1 f. ft ''-----NOV•..'7:._:•r' n n ,, I
To 9-5 f/, 21.REMARKS NO 1 1 21,23
V
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: j; ;, ,_,,Y Yi
(if well field,one 1at/long is sufficient) 2 ertification•
5S.agy0 b.18 N $ o . a l a59 W c e i 1.. 6 -a3
6.Is(are)the well(s)VPermanent or °Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to ad existing well: °Yes or cgNo 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 a d explain the nature of the copy of this record has been provided to the well owner.
repair under 1121 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: f SUBMITTAL INSTRUCTIONS i,
9.Total well depth below land surface: 35 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2QI00') construction to the following: '
10.Static water level below top of casing: al.55 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" i r 1617 Mail Service Center,Raleigh,NC 27699-1617
v 11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: , 1 A.Tela above,also submit one copy of this form within 30 days of completion of well
construction to the following: j
(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) Method of test 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount 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 Revised 2-22-2016