GW1--00444_Well Construction - GW1_20240116

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, WELL CONST;'UCTION RECORD(GW-1) For Internal Use Only:
' 1.Well Contractor Information: .r 24/P�+�'`+' 3
1 r1 5heti1/1 .
14,-WATERiZONES,�r.r r:"_"k'-...n.M::-.-;at; ,.-taMgC -:' ... v E r,
• FROM TO DESCRIPTION
Well Contractor IName ft. ft.
ft. ft. i 3-cR6
NC Well Contractor CertificatiiooJn Number 15'O,UTER GASI'l�IG(forIiiiati cased well3}OItx:]`;1NER,(IF=aji hcnble)as r, .:,.
1 I ° / f� 9 t�r1 4 r //L FROM TO DIAMETER THICKNESS MATERIAL` 7�)
e6 t� (/ J ft ft t m . �r�G� r /4�C`�f
Company Name )))� c16,IIMR IVSH OlaUBIN,G,;(e'ofhVilna e osed 14-ti r� :tg . S. -:10 3
2.Well Construction Permit#: I •
t/1 t7/ 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.
Water Supply Well: r 171sCREEN ,?,+ a .::f- ._r 1 i s 4 r::;.�v4' �.a.:xi..:r :.::, t. k `.:s:is a�.
PP ' FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
1 Agricultural 0MunicipaVPublic a ft. ft. in.
a!Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft.
*i Industrial/Commercial ID Residential Water Supply(shared) IS;iGROUT,,;:::. '{cs _,f.'_. "> :.. ..r,Y,:: . .. .. ,;
._``Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. tj ft. 1i1,71>�j Ft 2i9 C b/-
.Monitoring Recovery ft. ft. b e, (`� F xkly.-- )a by
Injection Well: ft ft. l3
It Aquifer Recharge OGroundwater Remediation
19;;SAND/GRAVELPACTf7tifapplicable){ .• n X. � 4.r. .....*4 _
ilki Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
R Aquifer Test 0Stormwater Drainage ft. ft.
ill Experimental Technology DSubsidence Control ft. ft.
1*Geothermal(Closed Loop) OTracer 20 DRILLI6IG"PiOG.(attacfigddthbneh?aheeisafnecessary)',:F^,i o`._
FROM TO DESCRIPTION(c lor,hardness, grain soil/rock type, size,etc.)
*Geothermal(Heating/Cooling/Return) ��0Other(explain under#21 Remarks) at /�ft. 'i U d
1,4.Date Well(s)Completed: / -•.it( 7 .Ja ,t Well ID# 3'ft. c ft. a t19 I 'i re
5a.Well Location 1"1 ft. �r,)Pft. R,il2 q/ylL' 6' y1JJ/)7a
ft. ft. - .,, f
Poll? Lirp f 41-thl Jiiit )vc ... f - ��
{ E
Facility/Owner Name Facility ID#(if applicable) ft. ft. r�n 6 jl.. 4i -
3 �' -�}`, yvl J '/l/ i 1�e1 dN /��- ft. , ft. JAN 1 6 2024
Physic"'kddress,City,and Zipft ft.
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21 REMAItRS.` ,;:v ft-ty?ll tea'`.-{'rIg1 :illiPiRiigN 1 s .5 I i
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.Ce tification:
vo. lp N 7/j> P201/4 W itg. 474i,1:) 1 - i - 3
6.Is(are)the well(s) Permanent or Temporary ignature of Certified Well 049 Pi
Con etor 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: £Yes or,/—,No with ISA 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 this record has been provided to the Well owner.
repair under 1121 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: ` SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 24)I (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:
10.Static water level below top of casing: W (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: • IF (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
. 10 /l/ above,also,submit one copy of this form within 30 days of completion of well
12.Well construction method: 1 J O7-r/' G construction to the following: 1
(i.e.auger,rotary,cable,direct push,etc.) 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
0 1
13a.Yield(gpm) IP Method of test' `/�T 24c.For Water Supply&Injection Wells: In addition to sending the form to
7-1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction tot the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources' Revised 2-22-2016
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