GW1--07489_Well Construction - GW1_20231120

WELL CONSTRUCTION RECORD(GW-1). For Internal Use Only:
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1.Well Contractor Information: '
is 1
� 14:WA'�RzoNEs � 1 '
Well Contractor Name FROM TO DESCRIPTION
3 L ft. I ,
NC Well Contractor Certification Number :,:15.:OUTER,CASING(for.tnniti welts)'ORLINER(if • )'
17ThO-qS FROM TO DIAMETER THICKNESS MATERIAL
Company Name
l���� 6.x6::I1vNi�,cnSn�rc.oli:T�rsnvc.( .do:al-I�n)
2 Well Construction Permit#: FROM TO DIAMETERTHICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,Count',State,Variance,eta) • ft is
3.Well Use(check well use):
Water Supply Well: ;FROMM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public• o ft: in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) /� I- 49 m .
Industrial/Commercial QRessidential Water Supply(shared) �'.... . ..
,411:GROAT?,. . . '
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft zo ft CrkeK ., d Ol....nn 1.'1 L( .
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
- Aquifer Recharge 0Groundwater Remediation 19..SAND/GRhV£L'Pd( #if9ppfiisbk}•.
Aquifer Storage and Recovery [ Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test (]Stormwater Drainage
ft Ltift-rA
Exl,etuuental Technology Subsidence Control ft.
it
Geothermal(Closed Loop) DTracer '...20;•DRILLING„LoG.(stittutb.additional SUetsfnt y)
FROM TO DESCRION(color.turdaass,so k type,il/roc Brain sine,etc.)
Geothermal(Heating/Cooling Return) [Other(explain under#21 Remarks) O do'IPT1
4.Date Well(s)Completed: q I Zi Well ID# • "1% ft S ft C 1 .
5a.Well Location: • ft ft
U.-Xi - 10 t r1 1 C. 0 ft ., .. .. . . • ,
Facility/Owner Name '^ 1.41.
e 1- Facility 11D#(if applicable) ft. ft. • T ,- ..
. 22 -(l�-% I ,r`��1.1e--1 5 IC .a - ft ft , ... .: 4,�,ii,_t `;;., F
Psysical Addiess,City,and Zip ' ...... . . . . .. . ft ft.
NOVJ 2c23�, -LL; , ..,
County ParcelIdentifcationNo.(PIN) • In;.. , _.1^:u ::),•. tr,.,
5b'Latitude and longitude in degrees/minntes/seconds or decimal degrees: DV;` O a
(if well field,one lat/Iong is sufficient) 22.Certification:
N . W 12 elIz-,Iz3
6.Is(are)the wells) Permanent or Temporary Signature of Certified Well Contractor Date
TTTTT��t4 AN:
By signing this form,I hereby certify thin the well(s)was(were)constructed in accordance
well: D7.Is this a repair to an existing welYes or with ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,ftll out known well construction informationain 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 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 nerpsnnry.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 10S- (ft.) 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 22@100� construction to the following
10.Static water level below top of casing: Q (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. CO (in) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: fr-Q+0-•"-t-1 .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:
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Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) I Method of test �"1/4.4't. 24c.For Water Supply&Injection Wells: In addition to sending the form to
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y1 • the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: I T'� Amount �, 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