GW1--00287_Well Construction - GW1_20240105

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1711111
1.Well Contractor Inforlopalion:
i iilO
— 3t rye \L , � S
Well Contractor Name FROM TO DESCRIPTION
t 3 6 ft* a)3 S '� 0��r:cc - 7. k S f
:Z,1 L ')- - 1k ft. ft.
NC Well Contractor \Certification1 Number 1 l lA t Ch 1 A lt,,e_ ` 1 �J !`\ r1 l , N C PROM TO ,' THICIQIP S MATERIAL
Company Name J 0 ft. (9 ft. 4Ja. 5D► .a1 4' ` c,
•
2.Well Construction Permit#: D a- — O O 3 3 FROM TO DIAa� 1HIC>OVFSe MA AL
List all applicable well construction permits(i.e.UIC,County,State.Variance,eta) ft. R in.
3.Well Use(check well use): ft R it
Water Supply Well: FROM TO DIAMETER SLOT S ZE THICKNESS MATERIAL
DAgdcu1 ual DMuni ' blic ft. ft. " In.
Geothermal(Heating/Cooling Supply) ' tial Water Supply(single) ft. ft. in.
0Industrial/Commercial 0Reaidential Water Supply(shared)
irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT_
Non-Water Supply Well: ti E ft* t. f L c €.,�N. b c.0 S S o b
CliMonitoring Recovery ft. ft. M Je L r-e
Injection Well: sr
ft. ft.
DAquifer Recharge DGroundwater Remediation
DAguifer Storage and Recovery 0 Salinity Barrier FROM TO MATES to L EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology ()Subsidence Control ft. ft.
Geothermal(Closed Loop) DTracer
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION Taoist,hardens naWraektypq pits due,sir.)
4.Date Well(s)Completed: 1 Ji /
3 WellID# S\ ft a30� C, '�s----,.Z, A--P
5a.Well don: n ? . ft'. a,3 ft- -C_( y Ce —1.t c
Facility/Name Packlityn (if21)00 114 ft ft
a C -, 1k t LL
(2- 0 Fburvtet,J ft. ft.
Physical Address,City,and Zip 1 f ft. ft. ..-�,
Lk"Ct .v'J e__ c; ,, `)4 `1 6 .)) 1 '4"--
County Parcel Identification No.(PIN) 024
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one lat/bng is sufficient) Oren PrM •
3 C �( t) j /� 22.C -lion: a�
5 3 N `� a 4 4-`1 w , �-t,( >,a, (R . ,
6.Is(are)the well(s) ent or 0Temporary Signature o We 1 Contractor Date
�''����� By signing • is form,I hereby certify that the Hell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: K*�Dyes or '.. with 15A NCAC 02C.0100 or 1SA NCAC 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 ibis 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 pug: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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (.) 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 2Q100') constNction to the following:
10.Static water level below top of casing: 1 va (ft.) Division of Water Reso arces,Information Processing Unit,
lfxuter level is above casing,use"+"L 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: Qn) 24b.for infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: �)C 0.T. `'"I above,also submit one copy of this form within 30 days of completion of well
(ie.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 2___-- 1636 Man Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) J— Method of test: `5 24c.For Water SmDaIV&Infection Wells: In addition to sending the form to
11 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: l\if 1 Amount: L a r L" completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016