GW1--07801_Well Construction - GW1_20231201

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
J am tsrx, f-
�?1 b. cx\ 'At WATER-ZONES :- : ):;: :_ r
FROM TO DESCRIPTION
Well Contractor Name •
I a
ft. 70,0 ft. 7,/6f/atod
ri0 ft' ///11 ft- /D//
NC Well Contractor Certification Number `-15 AUfER'CASING.(for multi=ciised wens)OR LINER(if ap licable)`
y/—��-C�� l�(� � I t ` '� FROM
ft. TO
ft. DIAMETER THICKNESS 1 MATERIAL
1 ! ! in,
Company Name
^^ ^� fi16:INNER CASING OR'TUBING'(geothefinaldosed-loopy- ::'. ''
2.Well Construction Permit#: .0 o2 3 A 000o I - FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) D ft. rr ft. J. 2r in. SDK
21
Pr/C
3.Well Use(check well use): ft. ft. in•
Water Supply Well: :17 SCREEN _- 1,,f. ;.-" _c ;,' ::.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunic pal/Public ft. it. in.
f- Geothermal(Heating/Cooling Supply) sidential Water Supply(single)
B ft. ft. in.
Industrial/Commercial (Residential Water Supply(shared) 'is:GROUT+' `t..; - ,, - .
f IIrlgation _ FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ._0. ft. JP() ft. ltefethik feltatc-
Monitoring EilRecovery ft. ft. `-1 f 4 7
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 0Stomiwater Drainage ft. ft. •
Experimental Technology (°Subsidence Control ft. ft. j
aGeothermal(Closed Loop) °Tracer 'r20:•DRILL-ING:LOG(nitacti:5dditionarskeets f necessa'
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soli/rock type,grain size etc.)
0 ft. S/, ft. Cray fay/dyer-Iva rdzQy�
4.Date Well(s)Completed: Jb-a 1-23 Well ID# SS' ft. .j`rt. area ri t Ale
5a.Well Location: ft. it
n ft. Pr---;. f �W 1,-,
Cis �} :, _ • --;' t> u n
Facility/Ow ame Facility ID#(if applicable)
ft. ft.
93g nab rot' M eel,�_`-l�e 1 Nc_ ft. ft. D_ 4 ? 2023
Physical Address,City,and Zip ' J 1r"13 ft. ft. c t_lC a?; ,:-A,;;r?3(;t•�:i
41:REMARXS :13k t, ✓a
lne dmle-e, 9 tag i'sa5 S'y OODC.J6 _
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(if well field,one lat/long is sufficient) 22.Certification:
35° 33' al. ? I" N $?° ?3' 3Z.-Iall w
6.Is(are)the well(s) ermanent or QlTemporary- -- -- - _ __rt of Certified Well Contractor Date
By signing this form,I hereby cerl fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: jYes or E 'o with 15ANCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain 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 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: ST7RMiTTAT.TNSTRTUCTLONS
9.Total well depth below land surface: )a t 1 5 (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 2@100`) construction to the following:
I
10.Static water level below top of casing: 5 0 O (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: (. .;1 r (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of:this form within 30 days of completion of well
12.Well construction method: R C Y construction to the following:
(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) i J Method of test:at:,.at:,. / ia
f. �.on , 24c.For Water Sunnly&Injec
r tion Wells: In addition to sending the form to
1 / 1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 1of11'\Q Amount: /0 ►eLL( completion of well constructions 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