GW1--00944_Well Construction - GW1_20240209

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: — g, I i
6Py' S he m ii Fi R°ATERZQNES. v':. .a. rt r,. n s;2.a.,.F,.ita-`,,, .
• FROM TO DESCRIPTION '"
Well Contractor Name ft. ft.
P -4 62,0e79A ' ' ' '
ft. ft. i
NC Well Contractor Certification Number 1'S:'OUTEWCASING(forMiilti.cased£wells)OR's>rINER�'(ifiip licatile):�/ u
l /
' 1 C V / ?tee i t FROM TO DIAMETER THICKNESS MATERIAL
ft ft. G2� er mr 0,3 d �U Lt57e1
Company Name s ,. x - --
yp 16`INNER.CASING OR:TUBINGi�othcebmahclosed,loop)r
2.Well Construction Permit#: 5 T /c_ 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 :17."SCREEN..' ;i .. . ..::tom' 4__`•- °n. . >:E._. '• .'_.
PP Y Well: FROM TO ¢DIAMETER - SLOT SIZE THICKNESS MATERIAL
Agricultural TrA Municipal/Public O ft. ft. in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
DIndustriallCommercial DResidential Water Supply(shared) ,;?
.SS'GRGUT s,^,. .�,e.�z..�zy� '-v.�; s'�"-�.•�'`� ��.._. , s s:..
[ Irrigation FROM ' TO a�TERIAL EM CEMENyT METHOD&AAM}OyUN;ii
1 Non-Water Supply Well: _19 ft. 1 ft. 7 y.�IjI�1� 4 v 6., .J JG'/J/47 µ//!i/i'I
Monitoring 0Recovery ft. ft. / ��JBU o2 q till d ,7
Injection Well: ft. ft. J
Aquifer Recharge 0Groundwater Remediation r19YisAND/GItAYEL PACIC'(if applicable). . - _W u fb ^". -W�` %='="_'
DAquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Or Aquifer Test DStormwater Drainage ft. ft.
01 Experimental Technology 0Subsidence Control ft. ft.
ill Geothermal(Closed Loop) DTracer 20:iI)RILLTNG-TA.G;(utiach.adHilionalsheeiiiifvecessary') x:
FROM TO DESCRIPTION(col ,hardness soiUrock pe,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft p I,ft Lc ref, p t�e
4.Date Well(s)Completed) , dA Well ID# t� i
ft. ,,6,ft. rp
5a.Well Location: I e kb ft- h/i�ft. /'u Iy jr "'PG,'
Yes-s T e DAB)10)7745' // 141o1 e 41 " — ft. ft. [ lk�(((��� :. ..
.,,,
Facil' /Owner ame Facility ID#(if applicable) ft. ft. c S
4 y„yi12 � t�17CC5V f f e ft. ft. Cd U Si 2024
Phys 1 AddressaCity,an Zip ft.. ft. ffiki7r iPn 7r
., Cede
__L,(J )$ :s21/REIWAARI`GStm gt Mn .x t;; Krk:Wd ,/:'.a(',ja-�r . ?//,v ,Vgi „sn•){,_
County �v/Jvu[i I Parcel Identification No.(PIN) `! Jt//P �' iiP-.-all.I ` v ezA
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: / "" �L� �L/// 1��
(if well field,one lat/long is sufficient) {fin 1 22.C rtification: �jfj/ e�Q `�
,9 ,5r3i.'2/5 N O�'! ek / W l�1 n7/�(/ 1/� .9 —d 41
6.Is(are)✓✓✓ the well(s) . Permanent or Temporary Signature o Certified Well Contractor Date
By signing this form,1 hereby cent fy'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EjYes or ', o with 15A NCAC 02C.0100 or ISA 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:
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: j . SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /f/)vn (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dlgirent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: I'I/ (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: V (in 24b.For Infection Wells: In addition to sending the form to the address in 24a
j� I' P0,t�7',� above,also submit one copy of:this form within 30 days of completion of well
r
12.Well construction method: /U y construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY7 WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) c PP Method of test 1 '�l 24c.For Water Suapiv&Infection Wells: In addition to sending the form to
}-{��- J�, the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: t ' / Amount: e 1 1 '7- 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 Revised 2-22-2016