GW1--01245_Well Construction - GW1_20240229

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 1
1.Well Contractor Information: j '
a`rntSan at bSC3''\
14.WATER ZONES i. .
Well Contractor Name FROM TO DESCRIPTION
•
tio9t.� - Pt- D ft- Zb r fL t :Rc3\-4-)
ft. ft.
• NC Well Contractor Certification Number _15:OUTER'CASING•(for multi-cneed swells)OR-LINER(Huy. Heabic) --"- .u-
�1^../ .3 te_V l / inc
FROM TO DIAMETER THICKNESS I MATERIAL
1 ft. ft. DIAMETER
Company Name -
-
0 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,C unty,State,Variance,etc.) C/I'1 ft. f,J rr ft-
/_0 2i In. �tR 2 1 P vC
3.Well Use(check well use): ft. ft. 1 , in. v
Water Supply Well: FROME TO t DIAMETER SLOT SIZE THICKNESS MATERIAL
IR Agricultural OM • ipal/Public ft. ft. in.
*Geothermal(Heating/Cooling Supply) E!'esidential Water Supply(single) fL ft, in.
*Industrial/Commercial JResidential Water Supply(shared) 18.GROUT . .. -
I Irrigation FROM TO ' MATERIAL EMP CEMENT METHOD&AMOUNT
Non-Water Supply Well: v ft. .20 ft. 8R�: ? Z
*Monitoring DRecovery ft. ft. .i le
Injection Well:
ft. ft.
III Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable).
*Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
liAquifer Test DStormwater Drainage ft. ft. 1
mg Experimental Technology 0Subsidence Control ft. ft.
all Geothermal(Closed Loop) [Tracer 20 DRILLING LOG(attach additional sheets if necessary),.- . 0'
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
*Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks)
C ft. Is-.-"' Clow 10 vUrb tAyzi fr
4.Date Well(s)Completed:p?')1-Z.4 Well ID# I S.rft. 3 OS ft- GI t
5a.Well Location: ft. ft.
5A-e-VC F 6ft. ft. ';* "' 'o lilftz t•-•
Facility/Owner Name Facility IDO(if applicable)
ft. ft. i G 't
aiS G0.?(�N.c.c1r� 'D(. Alf inn Me _ g'nki1 ft. ft. ; �t� 9 2024
Physical Address,City,and Zip ft. ft. tn431 p1.14.jeD Pr-,......
21.REMARKS I it/aa-t..••••.'-Y17tS-
Vc�l I�z3do�Z°�8'3Z '-,..,.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35°43139°S5g14SN %IQ51' 2-9.0682to9 l I w
- RI- L4
6.Is(are)the well(s) rmanent or Temporary tore of Certifie ell Contractor •
Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: IYes or El o with 15A NCAC 02C.0100 or 15A 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 d-r (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:
10.Static water level below top of casing: ( 0 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,usell"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: li,. 7 5.- in.
( ) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12 c+0.9 above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: '--J\ 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
13a.Yield(gpm) 110 Method of test: 5A1• CoilNA . 24c.For Water Supply&Infection Wells: In addition to sending the form to
uv the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: C,h\OnrO.._ Amount: 3 V0.17s 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