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Home My WebLink AboutGW1--00439_Well Construction - GW1_20240116 419 5 f ' I• 1.Well Contractor Infformation: I p/ffoke ii/y/ I :l�l WA1'ERZ(1NES'. ..."••:f•.' ;ccc.., - : !.... ,. • ..�i..:.�.?..::t. .� .,....�..,.... a r•5:•:4•„J Wel[ContractarNam/e� FROM ft. TO DESCRIPTICK; P ,} - 19 NC Well Contractor CertificationNumber ft ft. a `r^;J i) �) ! f I �g fd55OUTER:CASING(fo Etilti-¢asedwelli)ORLINERGU"'Viable);lenI::. :;i;"•;>;; f 4,/1l` 81,3 I r 4- FROM TO DIAMETER I I THICKNESS MATERIAL CompanlyName !' Vit. �7 j ft. /�j inr s pi a pif I / .r16:ftiergR'CAS rt. litlieemelbftiied-lna�2:A1331; :;% ?:M.:-Yg 2.Well Construction Permit4: , 0 PROM - TO . DIAMETER I THICKNESS MATERIAL List all applicable well construction permits(Le.UIC,County.State,Variance,etc.) . ft. ft. in. . 3.Well Use(check well use): ft. ft. in. Water Supply Well: ,117.•SCREEN::'.•„._;:< I?lls:M{%:?it?:•'.'s••i i,,.;r:i::..4°•'r .. Y?:: ;i'141 - .S 'i s,- FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL ,Agricultural IDMunicipal/Piiblic - 0 ft ft in. MI Ge.thermal(Heating/Cooling Supply) DResidential Water Supply(single) - h• ft.,- in. il dustrnaYCommercialIDResidential Water Supply(shared) ' .:Irrigation FROM TO TER/AL .EMPLA i MCMETHO & iT Non-Water Supply Well: 0 ft .J . . a• Y1 i =. -Monitoring rRecovery ft. rt. ' Vi e'1 41/-J 1- Injection Well: f'-! , , - _ •`� M'Aquifer Recharge DGroundwaterRemediation • Et ft --,CI,' °-� s:19:SANDIGRAVEC•PAC.@(ifapplieebie)i'„a.: 2ik a=s z,`:L;=?:>.:'.'.s t:":t "?Aquifer Storage and Recovery °SalinityBarrier PROM TO MATERIAL . EMPLACEMENT METHOD JI Aquifer Test • °StonnwaterDrainage f. ft AIExperimentalTechnology JSubsidenceControl ft • ft. eothermaI(Closed Loop) JTiacer ••20r'DRILLINGLOGbitttacbadditiiin`alaheetiifiiiiriiiry)': ;a::=iii?i .i:• w..;r:•. Geothermal(HeatingfCoolingReturn) nOther(explain under#21Remarks) • FROM TO DESCRnUOUtyolorhardaesssotVcoektype,Rearnsa.eleJ r / a tt �tt /3 ree_A v/-q� / 4.Date Well(s)Completed: --,) -3 Well ID# i o. 5i it )1.19 p elt • 5a.Well Location: &` L by tt 6 f^ft/vi le Y" l l/ - t t �T,i - J/9! f! ft ft Fac]i'q/O�waerName 1 }�� )� f� Facility IDI1(if a plicable) ft. ft. i -- f A Z, I)/V%7/-` t" 01! i f e Ili G13/P�)�/9 ft. -it - Physical Address,City.and Zip/ a2e„/4 ft ft. I •�- :- _ County .PatcelldeatifcationNo.(PIN) • ' JRN1G2__04 56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (Ewell field,o ie tat/long is sufficient) - $J� 22.Ce 'motion: ,_ � a iq ) 35. '?I ,P ' Z "/ W C„n /j', 2 Giv(xrr=,n . t_ 74, ,3 fJ t/�il� •j ' // �J�r�: i 6.Is(are)the wefl(s) rmaneat or °Temporary SignaeacofCem'SedWcll Contractor Date , By signing this form.I hereby certify that the wells)was()sere)constructed In accordance 7.blab a repair to an existing well: DYes or olZINO with ISANCriC 02C:0I00 or ISA NCAC 02C.0200 Well Construction Standards and that a Jfthis is a repelr.All outknosvn welt construction information and explain the nature of the copy of this record has been provided to the avell mveer. ' repair under#21remark section or on the back of this form.' 23.Site diagram oradditioaal well details: • 8.For GeoprobelDPT 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 TOTALNUMBER of wells construction details.You may also attach additional pages if necessary. drilled: ji .. SUBMITTAL INSTRUCTIONS 9.Total we➢l depth below land surface: I 0 (ft) 24a.For MI Wells: Submit this form within 30 days of completion of well For multiple wells list all depths l fdi Arent(example-3 Or end;@100) construction to the following: • 10.Static water level below top of c ing: (ft) Jiwaterleveltsaboveearinpaere+ ) Div➢sionofWaterResources,InformationProcessingUnit, 1 1617 Mail Service Center,Raleigh,NC276991617 11.Borehole diameter: U� (fn) 246.For Injection Wells; In addition to sending the form to the address in 24a 12.Well construction method: , above,also.submit one copyof this form within.30 daysp of cam 1ption'of well �/ �^ construction to the following: i (Le.auger.rotary,cable.direct push,etc.) I . Division of Water Resources,Underground Injection Control Program, FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636 13a.Yield(gpm) a Method of test:))i' )7'i P.r, 24a For-Water Supply&Infection Wells: In addition to sending the form to /74 Pe the eddress(es)above, also submit one•copy of this form within 30 days of 13b.D➢sinfection type:, Amount: �completion of'well construction to the county health department of the county ' where constructed. - Form GW-1 North Carolina Department orEuvimnmenta!Quality-Division of Water Resources Revised 2 22 2016 •