GW1--00930_Well Construction - GW1_20240209

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information: .
S/.A!1 V_Alk v1l /I 4,0 C14:WATER,LoNES a;7:w"kmt $• 3` 'wwµ e ;. m .v 3
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
ft. ft, 756.4 RAJ VO r 4I 1j
NC��Wey�ll//Contractor Certification Number 15OUTERCASINGT(foc-'mu7tt..c®seiliwells)OR'IsTNER;(if ap Gcable) ,
.0X?.�.1/ "-D.S, yAC FROM ft TO fr DIAMETER rn . THICKNESS MATERIAL
J� 37 z S�, ( Fr,-_-_
Company Name ' 6 I :i- -
�j 16ialNNER�CASING OR'TUBING(�eotherma c osed=loop)�4',.._...{���•ri�-x�:'��=�
2.Well Construction Permit#: 4� / 11 c* FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft. ht.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17:�SCREEN'�aW .flay it i f-SI a17, ::.. . r;ire ? _
PP Y FROM TO DIAMETER SLOT SIZE _ THICKNESS MATERIAL
X Agricultural DMunicipal/Public 0 ft. ft. in.
1 Geothermal(Heating/Cooling Supply) Lesidential Water Supply(single) ft. ft. in.
(Industrial/Commercial OResidential Water Supply(shared) x; �+ ,:: , „� i3O,::
18°GROUT :+ ,".gym .0 a _a.•�.a...
_,.!,Irrigation FROM , TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. Oei,Ld,77C,L TJ.� ./" f/ea)
,$Monitoring Recovery ft. ft. T 6
tr
Injection Well: ft. ft.
X Aquifer Recharge OGroundwater Remediation 3smYs ,,
1911SAND/GRAVEL.PACK(ifappli'cable) ,a iv :.
*Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
It Aquifer Test ;$Stormwater Drainage ft. ft.
$Experimental Technology 0Subsidence Control ft. ft.
It Geothermal(Closed Loop) 0 Tracer 20€;DRIL'LINGLOG,(attach.a3ditonalsheers;ifnecessaty) xvI ., '. _
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
X Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) ft'
t fr.
t r . ., T)�,5,r ; / 4 J�v.,,J(tars
4.Date Well(s)Completed: Well ID# dG ft. ft. gi e/C-1/4. -'-‘
5a.Well Location: 33 ft. 9rify ft. "41 -7,4}"' r'..,..,'\f 0 1.
.
/ 1 ft. ft. t \0..�%...r e
r'i2nrdd,ry C�itcl444- =/27Pr/ ,eA.Se. - FEB NA
Name Facility ID#(if applicable) ft. ft. F CD .0 9.
5—f/ g / ft. ft. _ �:
a n tlad5n 7'/ ,t �r s•latre
ft ft t(I§UUfir'�"it ''
Physical Address,City,and Zip (St►JC}l$OC"
,2VREMARKS±:`._ ' WL'W< .....: - _ ..., _ 7 1
very )9Y /77 v92 5I
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.Certification:
.3� Ii1 /1iJ93 ' ( Ng((2, -u 4' 2?0 w
•6.Is(are)the well(s) Permanent or Oi Temporary ,..„,4-,m/
(tore of ertified We Contractor Date
By signing this form,I hereby certi,9 that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: jYes 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 this 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:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: C SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: / 7.J (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
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10.Static water level below'top of casing: Gay (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,user"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Boreholery diameter: ` (in.) 24b.For Injection 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: i"d:/1i'y construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) /
. Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY`WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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• 13a.Yield(gpm) 7 Method of test: / r 1;'-P 24c. For Water Supply&Injection Wells: In addition to sending the form to
! the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: a�t,-II.e.- Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
es Revised 2-22-2016