GW1--00445_Well Construction - GW1_20240116

1.Well Contractor Information: i--)/i7t3 V5
-
. r6 dm/ 14.. . ��ii, :14.+wATER ZONES'.,... K.': .- .. . ••:ffc. ,�:�:�::+•��::�� •,..�f.•.,.:..._... , :t:... ..
1NPe1ICoatractorName FROM ' TO :^• DESCR1PTIQi ;,-: , ;.•
ft' I(9' liM at9 cq)e) ,=--1P ciPtn
ft. ft. it,
NC Well Contractor Certification Number
j_• ,_ t.•:r.•..
y"y p�� (� s'IS OUTER:CASING(fdrmiiltRitied Willi)OP:LINER(ifs"liable):..,../..,:•k..°;
z2,� `• ('i 8 P/p V�n,:+i+� FROM -TO � DIAMETER ; THICKNESS �M,A�T,E/RIAL y
Companyl'lame V 1�/ Y F bl • (0 fk 7 b ft• ini ' ,� Je t/GY�i� O,/
/17 _16:DII'lER'CASING OR:TUBING:(ttedtheimn1i:16ifd-1a8hIL1A::i3li%:
2.Well Construction Permit#: FROM - TO DIAMETER i THICKNESS MATERIAL t Y ,
List alf applicable well construction permits(re.UIC,County,State.Variance,etc.) ft. ft. in
3.Well Use(check well use): ft. ft. In.
Water Supply Well: :r17:SCREEN:iis....,i<'`? tz;::i.;4 i=::;:i<: .'ilk .us.y'::::r'!.ixi:�:se�';�i+ :: 5i . .
FROM TO DIAMETER SLOT SIZE THICKNESS BATERIAL
*;Agricultural DMunicipal/Public 0 ft ft in, .
i Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) . ft • ft in. -
*Industrial/Commercial OResidential Water Supply(shared) .. .
_ �185GROUPI.•'_. :i.:7•: C?'it't.'.•':i:.i, . ."t�rFic ;::`iciAi:'s :f�4'iiG:'' •'S�s:`•itj'az'.•:;-!`.
ij' 'gatton FROM . ' TO MATER/ALy , EMPLA . ENTM. OD& OUNrj
Non-Water Supply Well: • .0 ft. A4 ft. /�M1ci, ,� L�
i1 Monitoring )Recovery ft. dt. J2 ✓✓��
Injection Well: ft ft. •���
4AquiferRecharge DGroundwaterRemediation
*AquiferStorageandRecovery pp••��•{� Barrier •
d9rSAND/GRAVELPACIC(ifapplicable);'rf z;#:=;:lie,::<Z:" il'.r,:•!ii : ;'•.t
P_I Salinity FROM TO MATERIAL EMPLACEMENT METHOD
*Aquifer Test riStonnwaterDrainage ft. ft
4ExperimentaiTechnology El Subsidence Control ft. ft.
IGeothemial(Closed Loop) JTracer i20.'DRI:LING LOG(attsehaddithiliblebeeteifiii weary)';`=£: :i...,...:;t: . .
FROM TO DESCRIPTION(cob r.bardoesr.saWmek type.Cnta,as.etc.
..:Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) 7/ ( //
4.Date Wells)Completed:/ ' -1„ ' Well ID# 7Git " 7• ft.. /j ,i 4, ,
•
5a Well I,oca on �ft. oft- t w-.' 4a
P ��' . •ft. ft. �jy l S z,
EaciitylOwnerName Fa.ity ID#(if applicable) ft. ft. 6 "k^^- y W,, �e• „A. �+,
.. lt
3 0 7 O�1.I,-P- Rol t Le /11 ft. ft. • JAN 1 g 2.0?4
Physical Addiess.city.and Zip ft ft. j •
�+� '21 .....•..ra ny i s =?:a...r's' J:ay<:"•t'*'`:Q:a.:1> s.:,:..._1•.-4..'s:
County .PametIdentificationNo.(PIN) t 147, .71/ Lt ' J 4. 1 d� rJF3 r,31
1.• JD� ' .i 3.> P'27
56•Latitude and longitude in degrees/minutes/seconds or decimal degrees: -�� 6'
(Ewell field,one lat/long is sufficient) • •
3 / d N Y 1 r P 17 1/ 22.Certification:. _ •
ii
6.Is(are)the well(s) rmanent or OlTemporaey Signature Certified Wet[ out actor Date
�� By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
'P Is this a repair to an existing well: J Ed"aYes or.! with ISA NCRC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
!phis is a repat.frU out known welt construction information and arplain the nature ofthe copy ofthfs record has been prosided to the veil owner.
repair under#21 remarks section or on the backofthfsfarm. 23.Site diagram or additional well details: •
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this pageto provide additional well site details or well
construction,only 1 GW-I is needed. IndicateTOTALNUMBERofwells construction details.You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: c#J d (it.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list off depths lfdifferent(exampl-e-.3@2000'annd 2Qa 100) construction to the following:
10.Static water level below top of casing: a 2?b (ft.) Division of Water Resources,Information Processing Unit,
Ifwaterlerelis abate caring:use+~ 1617 Mail Service Center,Raleigh,NC27699I617
11.Borehole diameter: X ) (in) 246.For Injection Wells: In addition to sending the form to the address in 24a
��7.12.Well construction method: /Eij- i G fl ' above,also submit one copy of this form within 30 days of completion'of well
construction to the following; j
(i e.auger,rotary,cable,direct pusb,etc.) 1..
•
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WE IS?ONLY: �� 1636 Mail Service Center,Raleigh;NC 27699-1636
13a.Yield(gpm)_ ' 5 U Method of test: / ✓Vi/ 24c.For Water Supply&Infection Wells: In addition to sendin�the form to
d -{- •the address(es)above,:also submit one'copy of.this form within 30 days of
13b.Disinfection type: (' ! f Amount: CC lb.'r completion or well construction to the;county health department of the county
where constructed.
•
Form GW 1 Noah Carolina Department oEnvironmental Quality-Division of Water Resources I Revised 2-22-2016
•
•