GW1--01401_Well Construction - GW1_20240304

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
d-er. m-e7 P49.0-5') 14.WATER ZONES I
FROM TO DESCRIPTION
Well Contractor Name
ft. ft. I '
3 7.. / ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
F 15 if /-oil n!,J f/1� �jjL FROM TO DIAMETER THICKNESS MATERIAL
C // l 5 cG 0 ft. -7 ft. '1,.- in. i-sl
Company Name 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.UJC,County.State.Variance.etc.) ft. ft. in.
3.Well Use(check well use): R, ft, fa
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural °Municipal/Public 07 ft. (7 ft. ''tom.I in 1, of '10 c)file,
Geothermal(Heating/Cooling Supply) i°Residential Water Supply(single) ft. ft. , in.
Industrial/Commercial °Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
N n-Water Supply Well: 0 ft. 3 ft. Cry•4,f- i7,,erti4t/ 15 6(S
Monitoring °Recovery '7 ft. ft. Q"�v1 0,„, „,-(,,.. Pvw 60 f
___Injection Well:___ _ _ _ - - - _- _' _ _ -__ _ _
ft.-
-ft.-. _ _
Aquifer Recharge °Groundwater Remediation t
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage 5 ft. i-7 ft.
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets If necessary)
FROM TO DESCRIPTION(color,hardness,solllrock type,grata sin,ete.t
Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) 0 ft. (r ft. ion
n� la g�t
4.Date Well(s)Completed:1_2°`' N Well ID# [v D b-r ,S 6,4 ft. ft. C,,i,.
/
5a.Well Location: J ` ft. 5 ' ft. „/i Gig, (-7't;/SF-.'-rtUS
p,,ts(o.^- ( 6P1'd v-1-5Le �b r ft. ( 7' ft. ,6,�,,..
Facility/Owner Name Facility ID#(if applicable) ft. ft. I R
/ ;...
(415 rvl4/c.'e..../P./ 3;.,kSa.-v(�((e_ k/C 'Z bSY7 ft. ft. �.._� e.L.,`t.is do -I.:
Physical Address,City,and Zip ft. fL MAR °9 /_ Zfi74
7 s 7_--! 21.REMARKS-
County Parcel Identification No.(PIN) _ • -
DiPJOirt` '3�s
r7n.C.,Ster.klg WO
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one fat/long is sufficient) 22.Certific on:
3.4'03 b0 N 77, s"N04 W ! l- ( (---
6.Is(are)the well(s) Permanent or °Temporary t of Certific ell Contractor Date
By signing this form,I hereby centify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or i 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#2l remarks section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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
7 9.Total well depth below land surface: t (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: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
l i.Borehole diameter: 2- (In.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above,also submit one copy o I this form within 30 days of completion of well
12.Well construction method: ���SG construction to the following: i
(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) Method of test: 24c.For Water Supply&Ini I tion 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: Amount: 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