GW1--00259_Well Construction - GW1_20240105

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This forur can be used for single or multiple wells -
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Lm&UseOY:
1.�Weell Contractor Information; = I
1-e\` .i'11"1 ' fa\ 1` 'co.) l4.WATER ZONES
��'IL'1 FROM TO Well Contractor NameDESCRIPTION
--_�• i0 5". ft.
C# i E"l0 ft. '�ti"11Q ft.
NC Well Contractor Certification Number IS.OUTER CASING(for malti-cased wells)OR LINER(if up placable)
L_ K.)\ 1��11 1 ` FROM TO I DIAb?f$T'ER THICKNESS MATERIAL
W �� 11d�1CI ft. E'j ft 1 ` f � in. ) 1 G pY
Company Name -I
j 16.1NNER CASING OR.TIIBING.geothermal closed-loop)
2.Well Construction Permit it: 3gtgk-i i FROM TO DIAMETER T1nct4ylsss MATERIAL
List all applicable well construction penults t,e.Caun ! ft ft, in.
0 State,Variance,etc,)
3.Well Use(check well use): it in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. fr. R o.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. n.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT "
❑Irrigation FROM TO MATE121A.L ' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: C� ft. 26 ft D
❑Monitoring r;�e,0)f ou:'
❑Recovery ft' It
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACE(if applicable)
❑Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Test ft. ft.
°Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft _
°Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional.sheets if necessary)
FROM TO DESCRIPTION Wan,hardness,sarl/roek type.grain size,ate)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) © It f 0 ft- 1 G
4.Date Well(s)Completed: - Dk"-3 1 ft. ,n2�i ft $A*1�d i
'54-4hie.CI'5.
Well Location..: t 2C.i ft- 2b0 ft' b\o e, Ste fC.
rredg 11- 4 1, ' ft ft.
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Facility/Owner Name ft ft.
Facility!Oft(if applicable) `:\r t...; '�( j
ft fL
�.•...
1k1 2.\/6`eC.\C, ViCi4 a )t. -
Physical Address,City,and,Zip
21.REMARKS
ft. ft. INc 2024
1�C`IL.:.%r' rN rijN-Ot-ti
County 1 Pr &E$t•^,s.Ulu
Parcel Identification No.(PIN) [)Ww.t�;
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: _
(if well field,one lat/long is sufficient) 22.Certification:
:S 13''s a1 iv �b,22 1 w e%'�2 �� aG ,,, 9,- )7"-a3Signature of Certified Well Connector
6.Is(are)the well(s): ePermanent or ❑Temporary
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: Oyes or with 15A NCAC 02C.0100 or 1S4 NCAC 02C.0200 Well Construction Standards and that a
o
If this is a repair,fill out known well constructionInformation and explain the nature of the copy of this record has been provided to f,he well owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
8,Number of wells constructed: ( You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
For multiple injection or ran-water supply wells ONLY with the same construction,you can
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submit one farm. � 24.Submittal Instructions:
St.Total well depth below land surface: a (.-E�O (ft.) 24a. For MI Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3©200'and 2 100
Q 9 construction to the following:
Id.Static water level below top of casing: 36 f (�) Division of Water Quality,information Processing Unit,
If,rater level is above casing,use"{ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: Na' , Cl (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
L above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: t l" r-c`c T`>/ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3C-) Method of test (" 24a For Water Supply&Geotherngl Wells: In addition to sending the form to
�47 �\ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfectione: Amount 1 completion of well construction to the county health department of the county
typwhere constructed,
Fonn GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality
Revised lam.2013