GW1--01460_Well Construction - GW1_20240301

Print Form-:
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: �'a w
LA 94V 9
14:WATER ZONES '.1 I
Well Contractor Name FROM TO DESCRIPTION
3o , 4- `9. /Dv f. i. c -P»�
7
NC Well Contractor Certification Number A�D tt I �4 /'
15.• TER CASING(for mar'�ased''wells)OR LINER(if ap Rcable)
���{ 1 ' t• ������ , ��. FROM � TO � DIAMETER m THICKNESS MATERIAL -.
10,6
Company Name G"••V/ 6�
? 16.0 R CASING OR TUBING(geothermal closed-loop)oop)
2.Well Construction Permit#: t 2i - o 1$5 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(l e.UIC, ounry,State,Variance,etc.) ft. ft i in.
3.Well Use(check well use): ft' ft. m
17.SCREEN
Water SupplyWell:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural •cipal/Public ft. ft In.;
['Geothermal(Heating/Cooling Supply) 041esidential Water Supply(single) ft ft in.
['Industrial/Commercial Residential Water Supply(shared) 18.GROUT '
flhrigation FROM TO MATERIAL EMPLACEMENT IEI•HOD&AMO
Non-Water Supply Well: 0 ft. b 3 ff. er u4 f DGtr-e
Monitoring I3Recovery ft. D'Injection Well: �i ®, NO/C..L..C..fr ft vl
laid lb
Aquifer Recharge Groundwater Remediation -
19.SAND/GRAVEL PACK(if applicable)-
Aquifer Storage and Recovery E3Sal nity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test E3Stormwater Drainage 't. ft. I
IDExperimental Technology Subsidence Control ft. ft.
DGeothemtal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets it necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) D ft. 7 ft. u " C�e."
�4.Date Well(s)Completed: ll ID# ;7 ft ✓ 1 ft Zed Ci . ;.::'._ r
5a.Well Location: ✓ ' ft ft. P G
I( r l ,-.' :''�'- - -,-- .-
t •
,, - ft ft —T ,
Facility/Owner Name Facility 11)6(if applicable)
ifer
'_1'" #
oo / /-11s f0,1 //1, k/f/&hois cA _ /it ft ft ��A 1� 1 202
Physical Address,City,and Zip °� ��
f�tt;.t�� c!Rvna 9 L,e� 21.REMARKS i. , .tnhrTra:li i,�;..,: i:�1r�
County Parcel Identification No.(PIN) �eJQ/`B '- : •'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .
(if well field,one 1at/long is sufficient) �j _r -;22.Ce•
call In:
35. 7� N " 11r /6 W k
Signature of rtified Well Coghacto J Date.. .6-. :_
6.Is(are)the well(s) ermanent or ['Temporary !;m r S+j f F, , '� ;xs
si in this form,I her certi that the well(s)was(were)constructed in accordance
• �BY $!( S .l• �Y
7,Is this a repair to an existing well: DYes ,or,ll}•`o "' with ISA NCAC 02C..0100 or ISA NCAC 02C:0200 Well Construction Standards and that a T
If this is a repair fill out known well construction information and explain the aatirre of the copy ofthivrecord has been provided to the well owner ;. ^-,., L'
repair under#21 remarks section or on the back of this form. `••
diagram or add ,Y•°'
23.Site itional'well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same •
You may use the back of.this,page to providt jadditional well site details or well =>' •r.
construction,only 1 GW-1 is needed Indicate TOTAL NUMBER of wells' .constriction details.You may also attach additional'pages if necessary: ;:.: .',j:,1-;::.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 4g0 - (ft) 24a.For All Wells: Submit this form within 30;days:ofrcompletion of Well `. :- --
For multiple wells list all depths ifdifferent(example-3Q200'and 2Q100')a , -•. -
vv�� constnrction.to the following: +4 '`' .a`y' ';
10.Static water level below top of casing: /-4-` (ft) : Division of Water Resources,Information Processing Unit, ,
If water level is above casing;use"+" - 1617 Mail Service Center;Raleigh,NC 27699�1617:::-:i',-.' -:' . ;;••'
11.Borehole diameter: t./' (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a�c:,;.
s-.:•
above,also subinit,one copy of this forth'within 30 days of completion-of:well_i�:, -wn;�-;" -
12.Well construction method: construction to the following I .' :
(le.auger,rotary,cable,direct push,etc-) %.` '-:`.r - -
Division of Water Resources,,Underground Injection:Control Progra ,m',. '''-- •
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,.Raleigh,NC:276991636 ^ - ,• ,- •r
13a.Yield(gpm) 3 Method of test: 6W" 260 thc.•For.Water:Suonly&Infection Wells: In.addition to sending the-form to -• ' •
•address(es) above,:alto-submit
one copy of this form within.30-days of,
13b.Disinfection type: )/'/ Amount: /q®ff fir,,,5 completion of well construction to the'coimty-health.deparfinent of the county'- ..
where constructed. "- ;.
Form GW-1 ^North Carolina Department of Environmental Quality:Division of Water Resources• :Revised 2-22-2016