GW1--07798_Well Construction - GW1_20231201

I 1111E 1 U111I
WELL CONSTRUCTION RECORD(GW-1) For internal Use Only: '
1.Well
,Contractor Information:
VC 1 LSO( (Sl .bcbV) 14.WATER ZONES • !.'
PROM TO nESCRItTTON
Well Contractor Name Q ft. _"tI'v ft' 4.�011 O�
gpg3 - A TIC) ft. ? ft. Tl[.)tc0,,.5
NC Well Contractor Certification Number 15.OUTER CASING(for trltiltl-cased yens)OR LINER(liars.Ilcahie)
Y
t ./� t� FROM TO DIAMETER TInCKNESS MATERIAL.
-A co tG k )I,C_CJ.3.( 1 Vi C . ft. ft. In.
Company Name 16.INNER CASING OR TUNING(geothermal closed-loop)
2.Well Construction Permit It: FROMTo DIAMETER THICKNESS MATERIAL _
List all applicable well construction permits(i.e.(JIC,County,Stale,Variance,etc.) D ft. f O it ft. / Qiiti. e b i o' 1
l V 1 (
ft. ft. in.
3.Well Use(cheek well use):
17.SCREEN •
Water Supply►Yell:
FROM To mAME rtiR7.SLOT SIZE TIRCKNFS3 dL%TFRLIL
Agricultural Q icipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) tcsidential Water Supply(single) r ft. In.
Industrial/Commereinl [ Residential Water Supply(shared) 18.GROUT .
Irrigation FROMTO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-►Water Supply Well: p tt' 3d rt' 8t?�otK: t _ ��}�
Monitoring Recovery ft. ft. c,
Injection Well: ft- ` rt.'Aquifer Recharge Groundwater Re mediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barriei FROM ,TO MATERIAL .ElviprACEMENT METTIOD
Aquifer Test DStormwater Drainage ft, ft.
Experimental TechnologySubsidence Control it- n
Geothermal(Closed Loop)3 Tracer 20.DRILLING LOG(attach additional sheets if necessary)
DGeothermal(Heating/Cooling Return) .Other(explain under//21 Remarks) FROM TO DESCRIPTION color.hardness,soil/rock me orala,ha eta) i
4.Date Well(s)Completed: )I')(a'23 Well EN 1Ay D' Oj-rt. 6rexn(,i
5a.Well Location: n. ft.
4 t. a sea c 1? vvt& !t. ft. k „,.s.%, J .-. -
Facility/Owner Name Facility'Di:(if applicable) D' ft.
k )Ce.1, Leic1?.. i ikt 25 19¢' ft. ft. -� LacJ
�7� t+rl1 QlrWl ft. R 1r ,.,,.-
Phyysical Address,City,and Zip +/ q Inft;-: ==�^ . - ..'3 l.h.:;4,
.i..1-1�CC3fY'�Is�c !GA SSIcwof0 V 21:REMARKS_'`. L•'.:* i ;.: a
County Parcel IdentificationNo.(PIN) I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latAong is sufficient) 22.Certification'
356 361 11.11�1r$44 N 12° (41 3se.22Z0 .8''fw
II-kg- 23
6.Is(are)the well(s) rmanent or Temporary of Certi ed Well Contractor Dare
By signing this form,►hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ige with 134NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fall out brown well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair:o der a2J remarks section or on the back alibis 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 necc Cary.
drilled: $LRMvrcALL.QrETRITeTfoNR
9.Total well depth below land surface: 3 0 S (ft) 24a. For All Well.: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@20'�0,�'andd�2@l00') construction to the following:
10.Static water level below top of easing: t'C'U (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mal Service Center,Raleigh,NC27699-1617
11.Borehole diameter. (0•2 (la) 24b.For Infection Wells: In addition to sending the form to the address in 24a
shove aliFitil iiit tine copy-of this form within 30 days of completion of well
12.Well construction method: t��ri YlJ A construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) (G!j
- Division of Water Resources,Underground Injection Control Program,
FOR WATERSUPPLYWELLS-ONLY;. 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) S Method of test:Qr11, 24c.For Water Seppivt"1tlnleetion Weill: In addition to sending the form to
the address(es) above, also-submit,one copy of this form within 30 days of
13b.Disinfection type:CicAt its:Yt$ Amount: 3 63 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEavimamental Quality-Division of Water Resources , Revised 2-22-2016