GW1--00018_Well Construction - GW1_20231218

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Informa�tion:�/� ��
Gro,v-e, '`Alt Q,=. -14.WATER ZONES. --. ;
FROM TO DESCRIPTION
Well
(,Contractor
Name
?eft. )40 ft. `o w►
ft. ft.
NC Well Contractor Certification Number
Wizards
- 15:OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Water Inc FROM TO DIAMETER THICKNESS MATERIAL
ei ft. S ft. [ ; in. O ,�O i rat
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)o V t-+
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
WNater Supply Well: 17.SCREEN - -
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural IDMunicipal/Public 0 ft• ft. in.
Geothermal(Heating/Cooling Supply) rir- -sidential Water Supply(single) ft. ft. in.
DIndustrial/Commercial OResidential Water Supply(shared) 18.GROUT-
',Irrigation FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. crd ft. Pam,p4 I rG,f 1)�� „,, r/ / /&
Monitoring �i 'ecovery ft. ft. 1 "`
Injection Well:
ft. ft.
i Aquifer Recharge Groundwater Remediation
.19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
I Aquifer Test I�Stornrwater Drainage ft. ft.
- Experimental TechnologySubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary) -
Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sotVrvek type,grain size,ete.)
��,,`` ft. ft.
4.Date Well(s)Completed:j� �'dv2 Well ID# 1Q ? I (P3 ft. ft -
5a.Well Location: ft. ft. - �. ,..-.7 S.....y dj5•� 1
IJi ( iP '. ft. ft. DrC 1Fac /Owner Name Facility ID#(if applicable) ft. ft.
Q T1,1/ Lft °'iC/ s(J r ft. ft. u:. t•"f3,i 'S'.- ,. ..r� i�A,,
Physical Address,City,and Zip ft. ft.
lo2t2„r.,n 14
1.REMARKS ]
ounty �� Parcel Identification No.(PIN) 't 45-JIP, 'p l 6 A2S" ‘-eiC G.as7-14 llj
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t \./
(if well field,one lat/long is sufficient) 22.Certification: ,
36 'u‘ 57(el1 N —7g.ct6 .7 w 3„011� 1,
6.Is(are)the weII(s) rent or Temporary Signature of Certified 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: eS�or C3No with 15A NCAC 02C A100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out Mown 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: I SUBMITTAL INSTRUCTIONS i
9.Total well depth below land surface: 4agr c° (It.) 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@I00') construction to the following:
10.Static water level below top of casing: k /vJ (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: ( /( (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
p �/ above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: -f-6"4 construction to the following: I
(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 Method of test V(,'ty`'f 24c.For Water Supply&Injection.Wells: In addition to sending the form to
13b.Disinfection type: 1 (�4 the address(es) above, also submit one copy of this form within 30 days of
�L I� Amount; � completion of well construction to Ithe county health department of the county
where constructed.
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016