GW1--01314_Well Construction - GW1_20240229

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: '
J akpn tS(1 6 1 d ) 14.WATER ZONES.'
Well Contractor Name Na FROM TO DE[SSCCRIPTION
9D I ft- (CO ft. TIUtio
iaY ft. ska ft 1- Ll
NC Well/ Contractor Certification Number --15.-OUTER-eASINO(rormvlti-ended..ells)OR^LINER'(if n limbic)-------- -
I� n lf l� j inc.
C ` FROM TO DIAMETER THICKNESS MATERIAL
'� W r I 1 ft. ft. in.
Company Name
16.INNER CASING:OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: O/v rl- e 6 0 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) v ft. -1 D ft. ,Zr" v
1n. SO re z t I'\ C
3.Well Use(check well use): ft. 1 ft. in.
Water Supply Well: 17.SCREEN
FROM TO
Agricultural 0Municipal/Public ft. ft. DIAMETER SLOT SIZE THICKNESS MATERIAL
in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
9Industrial/Commercial DResidential Water Supply(shared) 18.GROUT .. -
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: a ft. d a ft- I 'G 1 . t -
Monitoring
Injection Well:
i DRecovery ft. ft. IlJ 7R�_k,�
ft. ft.
11
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test J Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) ITracer 20.DRILLING LOG(attach additional sheets it necessary)
FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) O ft. 1 0 ft. C1 0.
Overdo ( 0k\_
4.Date Well(s)Completed: .2 I a.1 a L( Well ID# -]p f• 56$ it ,('0.V1- r ,,,,, y
ft. ft. S p�'Ni®L1L VET)
5a.Well Location: as t l4
•
ft. ft.
C IAVyGlW-t I- NIMso. ISrth l t-ty 2 2 2024
Facility Owner Name Facility ID#(if applicable)
ft. ft.
'h kelky Reich 1")r. I`Ileyriv1tN' eI n,L Or7O ( ft. ft. Information Crn*441
±unit
Physical Address,City,and Zip ft. ft. 1] f r
fpuv m 6-e 91 1 4 -l4-1,4 9 21.REIVIARICS
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:
5. 4Ve3e) N 5S2- (D Li a n a w
6.Is(are)the Wells) _ ermanent or Temporary ignature of Certified Well 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: IJYes or ri,' o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
&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: 5 oS (ft.) 24a. For All Wells: Submit dills form within 30 days of completion of well
For multiple wells list all depths if different(example-3@2//00'and 2@100) construction to the following: 1
10.Static water level below top of casing: 1.r2 0 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing, .,use"+ 1617 Mail Service i Center,Raleigh,NC 27699-1617 .
rr
11.Borehole diameter: tO. 2S- (in.) 24b.For Injection 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: Rt°) 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: �n 1636 Mail Service Center,Raleigh,NC 27699-1636 '
13a.Yield(gpm) Method of testtt7i. . eaelfra fl€12 24c.For Water Supply&Injection Wells: In addition to sending the form to
r- f l the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:a I Df►�- Amount: i� TGt-6 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