GW1--01132_Well Construction - GW1_20240216

iP Int Form.
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor n Informatio � • '�
/i -V t e- G� 1= _ it Wogit' ONF,S ' t
Well Contractor Name [�// • FROM TO DESCRIPTION
f ft. ft. I
G�5 ,-- At ff. ft.
NC We1l Contractor Certification.Number /� 15`OUS'l1R CAt$ING`(for muld�c`ti"sedEwells)`.OTt>UINDRt(Ifap MOM?'l-� 0J h )I / ,I I^ FROM TO DIAMETER THICKNESS MATERIAL
1111////�111 l�l l�� (�U•f r�-i� ' ft. I14, ft ib In. t, J$j 3 tee)
Company Name/ /I � :-;1G INNER°(iI'ASINGt.O to. ING't(Qttotifi'r'nielsclas'eil�ioop) '
2.Well Construction Permit#: b 374/ FROM TO DIAMETER THICKNESS *MATERIAL
List all applicable well construction permits(i.e.UIC,County,State.Variance,etc.) ft. ft' In.
In.
3.Well Use(check well use): -
ft. ft.
A7:SOREENV-.,> fi, r .: - ,...
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft, it. In.
Geothermal(Heating/Cooling Supply) <j'Residential Water Supply(single) ft. ft. In. .
Industrial/Commercial OResidential Water Supply(shared) /18V.GROUTs ; l'Ai _ . ...` . : N s.•. ` .:,,,'.
Irrigation . FROM TO MATE T-ALI EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: /) B' v�d it' h ei-,pK(te- 96 re(& It )Dj,JS
_ Monitoring..__ Recovery ft. ft. (J
Injection Well: ft. ft.
Aquifer Recharge OGroundwater Remediation s19:SAND/GRAY.EL A1*(Iffupplit:atile) .,. ..
Aquifer Storage and Recovery ' DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test EStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer ::20i>DRILLING3 O:G;(attaofi;iidditiohhalisheei`o(fneaeasary)i>_'::.'.:r:.::_
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,eta)
Geothermal(Heating/Cooling Return) 0Other(explain under#21 Remarks)
-g 1oL— d ft' ) 14ft. cm'! ,;idyll Saxe jrAvel
4.Date Well(s)Completed: ---'2 Well ID# 5tt. �ft. �l -�e
ft. ft.
5a.Weil L cation:
Wat- n e— . ' KI t . . ft. ft. ,
Facility/Owner Verne - Facility ID#(if applicable) ft• ft, "-j.::: 1.7.,LPi V t „ •
4 4 e M e w _S�/a, ft, ft. L t 1 f LQ`
PhysicallA/Ajdress,City,and Zip ft. ft.
Parcel Identification No.(PIN) . ' DVIC r�OG
County _ ,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees; •
(if well field,one lat/long is sufficient) r�xyII M/ 22.Certification: �J L.}(�
25t 1,21L ' N r (/ ) , l /,30 W p _ p1—/o�rV /
,x-,i Signature of Certified Well Contractor Date
6.Is(are)the well(s)"1 Permanent or Temporary
By signing this form,I hereby cerlf/y that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or EiNo with 15A NCAC 02C.0100 or 154 NCAC 02C.0200 Well Construction Standards and that a
if this is a repair,fill out known well construction information aiidexplain the nature of the• cony 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 I 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: -6-5 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi different(example-3@200'and 2@100) construction to the following::
10.Static water level below top of casing: Q (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+"('I 1617 Mall Service Center,Raleigh,NC 27699-1617
4
11.Borehole diameter: 6 72 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: r O-rely�/ above,also submit one copy,of this form within 30 days of completion of well
' ) , 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
t
13a.Yield(gpm) t ' Method of test: A I Y' 24c.For Water Suanly&Injection Wells: In addition to sending the form to
1. f t the address(es) above, also:submit one copy of this form within 30 days of
13b.Disinfection type: (.J'_ Y'I Kt' Amount: ,r2L-L5 completion of well construction to the county health department of the county
where constructed.
Farm OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22.2016