GW1--07773_Well Construction - GW1_20231201

1.Well Contractor Informatra: � • ��•
/� 1��// i' I�.li/ ! 1 ••14.1WATERZt1NES`!n..'.'k:` e.;:%•::ek:i?'. :..•": :.._..::'i"',r.a.'i.` .,:::..:ii:-. .:L.a::
Well Conlnctorsro:ue FROM ft. ,TO. it DESCRIPTIt1V
,' :'/'`,/l L./ ft. ft. 1 j' I. ) Ip
NC Well ontractor Certification Number {{{ ! 4 ` j /
a -t.- i • 4S90UTER:CASiNG(foi'mrileaaedd"' 110OItLINER On-'lidsble)14:1: :;:.i:1 /
FROM TO . D ER I iTHICI S htATER)AL
Company Name r16 II�IIVER'CASIN60R TUBING:(aeotb'eimal eldaed=IuuP1` ,:= :mac-?-: :: 'a"=•;•,:<'w
2.Well-Construction Constructioa Permit#: bad �t� FROM - •TO DIAMETER I ,THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County.State,Variance,etc.) ft. ft. In!
-
3.Well Use(check well use): ft. it. In
'.
Water Supply Well: 17:SCREEN..\•.s. ,. . :s.''.::ic.N sS•if:�i,::%::='i.`.�icrz:.tsa °=:::'•:i,.::ens it cF :i ...tt' :tr.,•,
FROM TO DIAMETER SLOT SIZE , THICKNESS 1:MATERIAL
Agricultural riMunicipal/Public • 0 ft ft fa.
Geothermal(Heating/Cooling Supply) 'sidentiai Water Supply(single) ft. ft. in. 1 "
Industrial/Commercial ResidentiaI Water Supply(shared) yi$GROUrd . r. •.?1.i=.,.. .- .. _,;z?:: S.W::•:••::iZe js i:_ . JV:.. ..
Irrigation FROM TO MATERIAL EhIPLACEMEPIT METHOD&AMOUNT
Non-Water Supply Well: D ft '7 ft ge? ld j 7'? / /`
Monitoring Recovery it ft J�"� �] ,l f24/
Inell: �/, 9t27' /�,tt
Aquifer Recharge DGroundwaterRemediation
Sty StorageQp��Salini Barrier •i9:SAND/GRAVEL'•PACKCsaaiihcable) l:Az.l%:>:ii•.::::'rr Re3•!i;i _!•:: ;;`":f;:'
Aquiferra$ Recovery O tY FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test oStormwater Drainage ft. ft
Experimental Technology 0 Subsidence Control ft ft
Geothermal(Closed Loop) DTracer 20.'DRI:L1NGLOG(tilt\cfiaddititidilIbeebrifiiiieeiiiiiryl l V s'ivila-•.
FROM TO DESCRIPTION(cab r,hargoess.sollfrock sa.ele)
. .. Geothermal(Heating/Cooling Return) nether(explain under#21 Rematks) pry y1/
4.Date Well(s)Completed: !l ' q—( )WeUID# / •
1 „� ft 41/•7 ft - J 1V!�1 -
Sa.Well Location: / 1-174,fa bike- et//,1)/ )D tr=' (4. l/
e.
Facilityl/OwnerName }�,�� Facility ION(ifapplicable) ft. ft. . C `�c "S..'7i.,.i' Z3ice„'t.,}
J %�
/ (J P� Shc rP� /2r 02Y/tr 45// t1i'tr it ft. • Dr(' 1 1 Loll
Phy calAd City,and Zip • it ft •
// e el) . 0PiV :in:REMARKS`ti 2... ::. •f a:%.'iT-: 'e;'_:•`.r-: 1%:•;:i`Pa:;'firer:9r".3g•i -:•^,;......: ...
County .Parcel ldentificationNo.(PIN) C�/`1 y1 •J fir/ ! 1 1,19,6t��'�i1r �'i% 7.
•1
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Orwell field,one?a ong iz fficient) 22.Certification: j
N .61. 28, • w
as eralanent SignatureofC •fie Well on �� Date
6.IS(re)theweli() or ElITemporary u
�� By signing.thls form,I hereby certify that the welts)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or• with ISANCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well constructian information and explain the nature of the copyofthis record has been provided to the Well owner.
repair trader#11 remarks section or on the back of this farm. •
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 TOTALNUMBER ofwells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS !
9.Total well depth below land surface: "7 /�l✓ (ft.) 24a,For Ail Wells: Submit this form within 30 days of completion of well
For magpie wells list ad depthslfdprent(example-3(4200'and2©100) construction to the following: 1
10.Static water level below top of casing: J LC) (ft.) Division of Water Resources,Information Processing Unit,
Ifwaterlevetis above casing use" 1617 Mail Service Center,Raleigh,NC276991617
11.Borehole diameter: l%r�I (in) 24b.For Infection Wells: In addition to sending the form to the address in 24a
1 { ? /y� above,also submit one copyof this(form within 30 daysof corn letion'of well
12.Well construction method: // i.9 �1. k1/J7 r� construction to the following: I. p
(ie.auger,rotary,cable,decctpusb,etc.) I y
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: j - 1636 Mail:Service Center,Raleigh,NC 27699.1636
13a.Yield(gpm) .5 Method of test:N/t I/ T 1 24a For Water Supply&Infection Wells: In addition to sending the form to
�
/j �•- the address(es)above,also submit�one'copy of this tblm within 30 days of
l
13b.Disinfection type: / / Amount: / Z7 'fir completion of•well construction to the county health department of the county
• where constructed.
Form GVJ'l North Carolina Department of Environmental Quality-Division of Water Resources Revised2222016
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