GW1--01149_Well Construction - GW1_20240219

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well ont�a �nformatii • 1
/i 11�--JJ}}-- (� z;l'A:�IVATERT7QIVES
I FROM TO DESCRIPTION
Well Contractor Name - f(, ft.
NC Weontractor Certrtificatio Number11 CTi` /y/') �j� /�`' 15'OUTER CAS(IG(fors'in6lHvcased;wells)OI23I iNER(If.ap Ilcablg)': •
,] / I t/ / r"Y W, /-l V• FROM
fL TO ft. DIAMETER tn. THICMATERIAL
P > 1 81 4,t0Z5_. - SUS. Tii 1..:J7 L ,
Company Name / } �fs 3lt,.11NNER CASING:OR1'1?, INQ':(¢cotlielnal;elosed loop) '
2.Well Construction Permit#: S W,2-J d 9 I 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.
s1.7,4SCREEN � r_'., ;. : . ,:.: ::.
Water Supply Well: FROM TO DIAMETER SLOT SiZE THICKNESS MATERIAL
Agricultural 0Municipal/Public ft, ft. In.
Geothermal(Heating/Cooling Supply) 1'Residential Water Supply(single) ft, ft. In, .
Industrial/Commercial E3Residential Water Supply(shared) ";18;GRQUT 5. ..f-: '.s; . 0 i. . ...�.s ::_ >�'
i Irrigation FROM TO MATE TAL s EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. D ft' h&'Yt 'erti7e 0.b 5 nb are,d
:.:Monitoring 0..�.Recovery ft. ft. I I
Injection Well:: - - -- -- ... ft. ft.
Aquifer Recharge 0 Groundwater Remediation '.- .SANPf ,PA IC(iffapplleable).::f. _-: . ,,- .
Aquifer Storage and Recovery ' ��'Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test EtStormwater Drainage ft. ft.
Experimental Technology ,' Subsidence Control ft, ft.
Geothermal(Closed Loop) '' OTracer `•i;20>11RII ti'TNG T O0(otteo)i;a21i11tionet?sBeats If:neaessary).:,.• :. : .
FROM TO !DESCRIPTION(color,hardness,salt/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) Et Other(explain under#21 Remarks) ft �y U ft .d !r 4, ( Imo,r
4.Date Well(s)Completed: t-1--)-C'/ Well ID# q 1 ft. 265 ft' �'1'tu'1.i
ft. ft.
5a.Well Location:
/G‘ kete- il.a-114'10 A 1, -- ••—....:
Foci it ;/Owner Name Facility ID#(if applicable ft. ft. `-.G, d j ,:•.,
•
) 3 v l e- - tJ ) l 1 KiE 06. ft. ft. Fr., —a V,,,�6✓.'.,
Physic ddress,City,a d Zip ft. ft. Ulf- 5
KLL V(L vrotit ;21.1REMAIU1CS'zi r `?at: '
County Parcel Identification No.(PIN)- �(�e ',ty�.„::/(-: '
Sb.Latitude and longitude In degrees/minutes/seconds or decimal degrees: ,
(if well field,one lat//loingpis sufficient) Q i �//� / 22.Certification: �` ,
3 5 2111 ) 6P N -O Ili ( l W � t.e/ r'I/\ /"! .`)
r . Signature of Certified Well Contractor Date
6.Is(are)the well(s)•..:!Permanent or Temporary . -
By signing this form.I hereby certt&that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: E3Yes or .ffltNo with ISA NCAC 02C.0100 or 131 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 reindrks section or on the back of this form.- - 23.Site diagram or additional well details: •
8.For Geoprobe/DPT or Closed-Lbop.Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. (indicate TOTAL NUMBER of wells
drilled: //,, L�/� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 61 (ft.) 24a. For MI Wells: Submit this form within 30 days of completion of well '
For multiple wells list all depths if different(example.,3@200'and 2(4;100') construction to the following:
,an
10.Static water level below top of casing: �/ (ft.) Division of Water Resources,Information Processing Unit,
If water level Is above casing,use"+" i ' 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: Z/2/• 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: I's b G.11 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) 9e Method of test: a--/ I 24c.For Water Supoiy'&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: C'``'P/)< t Amount: r u-S 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
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