GW1--01150_Well Construction - GW1_20240219

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information: 1
AYyCi7 f' A-- I// e-tt — ;1:4;?,W3d H1tkZONES";;?'> 7a?rii;'y `.'..;_;`::.i.,;:.l;. '. ,':' •
WellConntraactorName v • .FROM TO DESCRIPTION
. - G F fi sA ft, ft
ft., rt'
•
NC W l Contractor Certification Number 9r5e KIIIIE=: A$ING'(for multit e`se dki ell`s)`•OIt IANARi( ap livable) ., • . .
FROM TO DIAMETER THICKNESS MATERIAL
�}� S t�/l/ �✓ �/� 6. n L, / ft' rg--Q ft. 4-1-?tin• S DR)," P VG
'Company Nami r. g c T6 INNEICOASING:`QRII• INt3":(pootlieiiiiil ieSed=1'oelr) :.
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2.Well Construction Permit#: 5 ,7 �� ��� / FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC, unty,State,Variance,etc.) ft. ft. in. .
3.Well Use(check well use): ft ft. in.
I Well: Ntili SCREEN,' �, i„ - ` .:• :
Water Supply P Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. , in.
Geothermal(Heating/Cooling Supply) 'I'll Residential Water Supply(single) ft, ft, In.
Industrial/Commercial OResidential Water Supply(shared) ?9113:1GRGU'[%`; ' ., r•. >_- i ,_
c Irrigation . FROM TO MATERIAL EMPLACEMENT METHOD&A OUNT
Non-Water Supply Well: D ft ,26 ft. ho„r{ 4-f •/ '6 i(�s- nb 1L1•e2
•
Monitoring Recovery ft, ft. �/
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation '
:319;:SAND/. RA`VEL'P4GK;(trsgpplltelile)ie=
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft. '
Geothermal(Closed Loop) OTracer •20:,>?RIISIiING•T OC+f(ettseh.iidditienelisheet's:fflaecessery)_ -
FROM TO DESCRIPTION(color,hardness,solUrock type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) �-
/ �•� f' /{f !' ft. a!r-i /,i/ y
4.Date Well(s)Completed: / )0 -�`1 Well ID# . 1(/C)ft. /-0 5-rt. LI/LA)is
5a.Well Location: Pi
'� ( I r ft. J ft.
A. ktzto-tm 0
Facility/Owner Name Facility ID#(if applicable) ftI I'V: LA 1.—t l? .1•".-d
- ' 3 / g10 N� a ,,?__Z, 14 w/ rt. it.
Physics dress,City,and ft. ft. :, [CD 1 0 t0e4
a � t
s �1 /1 po 24�REiVIAlrilS ::'
fir o 1^ I. 111x,us,mi. .. ...•,, .., ... -:.
County Parcel Identification No.(PiN) - I 1'1_Nt`t;n'i"
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees; • ;
(if well field,one lat/long is sufficient) 22.Certification: r�' Q f� ,)
•
� t71v N r 7o�y W / ' /f( �i�2-,)
r`ij' , Signature of Certified Well Contractor V Date
6.Is(are)the well(s)II Permanent or Temporary _ 1
By signing this form,I hereby certffr that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: *Yes or Igallo with 154 NCAC 02C.0100 or 154 NCAC 02C.0200 Well Construction Standards and that a
If this Is a repair,fill out known well construction bllbrmatlon and explain the nature of the " copy of this record has been provided 10 the well owner.
repair under#21 re)narkr 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-I is needed. Ihdicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
I
9.Total well depth below land surface: 6' (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:!
10.Static water level below top of casing: 7.0 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use'•+" 1617 Mall Service Center,Raleigh,NC 27699-1617 •
11.Borehole diameter: Qv/L' (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: {� �a 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 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: G(...) vs 24c.For Water Supply&Infection Wells: In addition to sending the form to
t the address(es) above, also tisubmit one copy of this form within 30 days of
13b.Disinfection type: (2-h f 0 f"-1 VL E- Amount: A. G l 5 completion of well construction to the county health department of the county
i where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016