GW1--01152_Well Construction - GW1_20240219

• lr ,c�POnt Form:
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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well C ntractor InformatP_2a
(ILY r e
14 WATErtzoNES e» 2. 3asrcaw:,, °. T. `'--.
WeIlContractor Name FROM TO DESCRIPTION
*5-14.TA ft. ft. 1 '
NC Well ontractor Certification Number ///III �f ��/ 15;OUTTERCASINGIfor'multi:cesediwellijtOWLINEfeft t ti Viable); ▪ _
pv V l�j f 1/l� �D, /xG , FROM TO DIAMETER THICKNESS MATERIAL
( l r / /j / ft. 17 q ft. 6, i zgn' 5 p t) /'i l..
Company Name / t16*INNERst ASING ORTUBING'1(Reoth sed"51efinaltelo 4) i„::
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2.Well Construction Permit#: / /) 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.
r17:SCREEN --- ;' .a• -i r . ,-'.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MA▪TERIAL
Agricultural OMunicipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) :'Residential Water Supply(single) ft. ft. i in.
Industrial/Commercial OResidential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 02.0 ft. h,. nl(e 13 bozos- fie)a-red
Monitoring - Recovery - . ' _ ft.. ' ft.
Injection Well: ft. ft. .
Aquifer Recharge 0Groundwater Remediation
19.'SAND/GRAVEL:PACK(Iffappheable), '- -
Aquifer Storage and Recovery ' OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test '" 0Stormwater Drainage ft. ft.
Experimental Technology \' 0Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer -201 DRILLING`LOG(attach"addltionalsheetS if necessary} :'- :
Geothermal(Heating/Cooling Return) Et Other(explain under#21 Remarks) FROM TO DESCRIPTION(color hardness,soil/rock type,grain size,etc.)
ft..1 et 'i9 �r rt c-1 a
4.Date Well(s)Completed: /r (-2 ! Well ID# gD ft. �45 ft. j itn j re
ft. ft.
5a.Well Location:
ft. ft.
5te—VeExv! yL
Facility/Owner Name Facility ID#(if applicable) ft. ft.
- A.c-Ynss-Prohm-257 t i. e AVE. ft. r-- -_
Physical Address,City,and Zip t ft. ft. d 1�, i '� "'
RU:t'e zs r-d- �-21:REmmucs �a, , s: ,-4_::r `:r'L � � --, „`- ,
County Parcel Identification No.(PIN) _ - f ` 1 Il 2074
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: • tnii;f,r, rp;, : ._, M+�,
rag um
(if well field,one lat/long is sufficient) 1 //D J�j (� 22.Certification: v 03,3�,G
C�J' ��d —'�d N �� l I �d W � / A q -114
6.Is(are)the well(s)r1iPermanent or OTemporary
Signature of certified Well Contractor , Date
By signing this form.I hereby cerl fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ENo_ . _ with 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 reinarks 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: t_k('5 (ft.) 24a. For All Wells: Submit'this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
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10.Static water level below top of casing: jft (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+"i 1617 Mail Service'Center,Raleigh,NC 27699-1617
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CO /1l 11.Borehole diameter: (in 24b.For Infection Wells: hiaddition to sending the form to the address in 24a
1/ above,also submit one copy of this fonts within 30 days of completion of well
12.Well construction method: �� a-i' 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
r
13a.Yield(gpm) ) Method of test: Q-/r 24c.For Water Supply&Infection Wells: In addition to sending the form to
/� rr� ‘ the address(es) above, also submit one copy of this form within 30 days of
I 13b.Disinfection type: i!'L10 Y/)i e. Amount: ,q (.GI-f)4. completion of well construction to the county health department of the county
/ where constructed.
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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