GW1--00484_Well Construction - GW1_20240116

,I.Well Contractor Information: - lY/P'S oil t -
y j, • 0l :..:..::.....:..:,:.
r G / :14JWATERZONFs'.':'4 1` .. , r:ti-..'.';.::. . '::1: ., .4,...:...._. -. ;,: ..
Well Con ctor�Name FROM TO DESC1tIP ICN. ,) a /
NC Well Contractor Certification Number ft. ft. Y/ 1 /�a 'P
A� l ::15:OUTER:CASING(fos5ialto#`aaiidwelts)OICLIPLER(if a"liciib2e)"i-::s;:.:;:.,:?;';:
/` ! )/ `� FROM TO DIETER THICKNEE��S DIA RI ,'-t
0 ft. /9, ft. . imp 5 9 is, t._
Company Name �y 2:9 .16:INNER'CASINGOR.TUMNG:(Reothirm rddi d460)'• 43:i'si4V.," ::••'.;:=.?i'.i :t
2.Well Construction Permit#: FROM - 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:
)7VaterSupplyWell: 17:SCREEN i:V.!,.., . E!:;a:= - :4ti::i'.it.j4K:: '.. :: ;V:nraii'F 'a , €a: .
FROM TO •'DIAMETER SLOT SIZE THICKNESS MA RL1L
MI'Agricultural DMunicipal/Public : U it: ft in.
?Al Geothermal(Heating/Cooling Supply) DResidential Water Supply(single)
ft !w in.
*Industrial/Commercial )Residential Water Supply(shared) H8r GROUT.^:': ..'..:1,.:'s�•i . . ;�iFi:: ^:;�:•-'�?;. '."•}'t is�•:. ..
gation FROM TO. .,. TERIAL` EMPLACEMENT METHOD&AM UNT
Non-Water Supply Well: ® fc it: ije fN A la19
Monitoring DRecovery it: ft t/P Ii1 1-jig 5 Pt f yy.ee
Injection Well: it ft
AquiferRecharge r3GroundwaterRemediation �Y!j
L� _�
Aquifer Storage and Recovery Salini Barrier ='FROSAND/GRAVEI:PACIO ifaaaliUebiey.' c=:r• 1WirtACEM:.. METHOD
'i:*r;
!-! toy FROM TO MATERIAL EMPLACEMENT METHO
Aquifer Test f StormwaterDrainage ft. 'ft '
Experimental Technology ID Subsidence Control ft ' ft.
Geothermal(Closed Loop) r3Tracer ';20JDRILLiNG LOG(aftiicbadditiSoallbeits ifheces'iaiyI: :4:.
. Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks)-•
FROM To DESCt+SPTION(ec9icr.6nrdne))ss.sai?finekp yJ etoi
rr++ Q ft cc ft �5 Lam) er2)p �^ /
4.Date Well(s)Completed:'A 4 hY Well ID# 1 f.cft. 6 d ft. • fi p i c/c *T
5a. ellLacation: �X ft ./pi,ft. l.1/e . .1p gc (_i�I IVY i!
FacfiitylOwnerName Facility Mil(if applicable) ft. ft.• I �•-: •" -,,
fs Z2e? J3 C)) JQ9 g 5/T e 7, RAA/}e ft. ft. 1 ' ''' b..,.'y...,..► v�;. _P
Pbysical i ddiess,City,and Zit) 9/7. ft. ft. J a N 1 h.
County . .PareclldentificationNo: ;Iflivr7?:r^�i�rn o -; ,. +,
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .
(Jewell field,one tat/long is sufficient) • 22.Ce :cation: •
�> /� 2(_s�
6,Hs(are)thewell(s)�Permanent or �ITemporary
signahaeofCe ed el ontraetor , Date
� By signing-this form,I hereby certt that the iveli(s)was(were)constructed in accordance
'Lb this a repair to an existing well: D lD+`aYes or. with ISANCAC 02C.0I00 or ISANCAC atC.0200 Welt Construction Standards and that a
Ifthis is a repair fill outta:own well construction information and explain the nature of the copy ofthis record has been provided to the Well owner.
repair under#21 remarks section or on the back ofthisform. •
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 page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTALNUMBER ofwells construction details. You may alsnattach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
p�
9.Total well depth below land surface: (ft•) 24a.For AlI Weill; Submit this foim within 30 days of completion of well
Formultiple wells list all depths tfdlfferent(example-3(0200'and y construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casln&use-4- J. • •1617 Mail Service Center,Raleigh,NC 27699-1617
11,Borehole diameter: (s (in) 24b.For Infection Wells: In addition to sending the form to the address in 24a
��� � above,also submit one copy of this form within 30 days of completion'of well
12.Well construction method: construction to the following:
(Le.auger,rotary,cable,direct push,etc.) . .
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: p . t .- 1636 Mail Service Ce Iter,Raleigh,NC 27699/636
13a.Yield(gpm) G' , Method of test: � J�, 24c.For Water Supply&Infection Wells: In addition to sending the form to
per] /� ' the addresses)above, also submit One'copy of this form within 30 days of
13b.Disintection type: / 1 • Amount: ! completion of'well construction to the county health department of the county
° - . ' •where constructed. i
FormGW--I North Carnlina Department ofEnvironmental Quality-Division ofWaterRescurses Retised2.22 2016
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