GW1--07405_Well Construction - GW1_20231117

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WELL CONSTRUCTION RECORD(GW-1). For Internal Use Only:
1.Well Con rrf rmation:
f D 1 hI r `" ) 14-WATERZONES 1 .
Name FROM TO DESCRIPTION
Well Contor 0 li ft. / oft.
ft. ft.
NC Well Contractor' ration Number IS..OUTER.CASING(for )OR LINER-(if • )
/ FROM TO DIAMETER ThICK NFSS MATERIAL
4.taw r ft. �j'� ft. 6, 1 m. /(f L
Company Name / / j 7 •16:INNEIf:CA ttNG.31%;11 BING.(t eot erjad dined-loop)
2.Well Construction Permit#: P/ti / 7 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U)C.County,State.Variance.etc.) ft ft. 1°
3.Well Use(check well use): ff
1.7
Water SupplyWell: EN`
FROM DIAMETER SLOT SIZE THICKNESS MATERIAL
QAgricultural DM 1pal/Public a fG ft in.
JGeothermal(Heating/Cooling Supply) Mesidential Water Supply(single) ft. in: .
DIndustria11Commercial DResidential Water Supply(shared) .:/ft_ GRona . • • .
' Irrigation FROM TO MATERIAL EMPLACEMENT METHOD& O/UNT
Non-Water Supply Well: ft ad ft. Co t Ct/.a- lC cs el n /P
Monitoring E3Recovery ft. ft.
Injection Well:
ft.Aquifer Recharge 0 Groundwater Remediation
Aquifer Storage and Recovery • DSalinity Barrier FROSDniLPACK MATERIALk} EMPLACEMENT METHOD
0Aquifer Test DStormwater Drainage f.
0Experimcntal Technology Subsidence Control ft ft. •
DGeothermal(Closed Loop) Erracer •28:DRILLING:3AG.(attaehaddiebaalsheeisitiansissary)
Geothermal(Heating/Cooling ) °Other(explain tinder#21 Remarks) FROM TO DEscx�tro r ea.ace soil/rock type, a me etc.)
4.Date Well(s)Completed: /// 9��� Well IIIt# �.f 7 5— //..--4
Sa.Well Location: ft. ft.T s 4 e 'e5 4A ft. ft.
FactlitylQwnerl /l� Faet7f applicable) ft ft a� .'
Physical City,and lap �,1/ ��� ft. _ f ,t• V ,�.�z
ZL REMARR5 NO V i ,, n n
`�CJ
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/secouds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification: ' J
N W /l/743
6.Is(are)the well(s) ermanent or Temporary Signature of ed Well Contractor 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: ®Yes or . No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out brown well construction information and explain the nature of the Copy of this record has been provided to the well owner.
repair under#21 remark section or on the back of thisform.
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 nerescary_
drilled: SUBMITTAL INSTRUCTIONS
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9.Total well depth below an surface: 7.� (f-) 24a. For All Wells: Submit this farm within 30 days of completion of well
For multiple wells list all depths ifdrfferent(example-3®2 'and__2(Q100`) construction to the following
10.Static water level below top of casing: V (ft.) Division of Water Resources,Information Processing Unit,
fwater level Is above casing use"+" - 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter (in) 24b.For Injection Wells: Iniaddition to sending the form to the address in 24a
12.Well construction method rB
above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) / construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
CCr
I3a Yield(gpm) J Method of test: 4' 24c.For Water Supply&1 i iection Wells: In addition to sending the form to
/� the address(es) above, also submit one copy of this form within 30 days of
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13b.Disinfection type: "! 7 /� Amount: 9e)_ completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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