GW1--01552_Well Construction - GW1_20240308

I
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Pe(!U( . Imo. P vust el,_ 14.WATER ZONES
Well Contrac orName FROM TO DESCRIPTION
- l9& R• )2DO ft• ;.01 of ,
3 J l ( ft. ft.
NC Well Contractor Certification Number
}�1 f,, r 1 _' I 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
l�)-e- is!- \ 1Al/,!t P �I lI I Lt1 (l4c FROM TO DIAMETER THICKNESS MATERIAL
I j.�... ft. 3�'+ ft. 4 ytf, in. /Pv�/(7 sV c.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit it:
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.
Water Supply Well: 17.SCREEN --
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) 'Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0ft. , ,UJ'ft. ecia /l//j, kt GT
['Monitoring ['Recovery ft. o�.o ft. Battlettac pit 9
Injection Well: ft. ft.
y e
❑Aquifer Recharge ['Groundwater Remediation tt
•
['Aquifer Storage and Recovery ['Salinity Barrier FRO IND/GRTO L PACK AATEERappliIA le) Ai/4- EMPLACEMENT METHOD
['Aquifer Test ❑Stormwater Drainage ft. It.
❑Experimental Technology ['Subsidence Control ft- ft.
['Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks)
FROM TO DESCRIPdTON`olor,hardness soi0racktype,Brunsizeetc.)
l (0 ft. .j ft. .�/ SD,
4.Date Well(s)Completed:4-a// Well ID# c g I/°i 7 fw ft.
5a.Well Location:. ;3,0 ft, #20 s_ ft.. /' r e -
4/ ..5 t. ft. fr.
Facility/Owner Name Facilityn)# a livable ft. ft. �'; o., v 9-..A�' tt
(ifapplicable) { kg c,L
/6 Gt) 'U f; u,,t r //ailsoa /44" -2f7.5�3 ft. ft. Mlt�u 2021
Physical •
` Address,City,and Zip H- H-
V t C e. ©Ss9 o i /7 21.REMARKS 1 i:�r i" t 3'-..< .f ew ;1,10
County Parcel Identification No.(PIN)
DVIC,t;50G
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22: tification• _
3C . 2( ic3 N ' 7 ' . 2..c.9 J.-z / w .
o‘,//472-0.=-11-
6.Is(are)the well(s):Wermanent or ❑Temporary Signature o Certifie ell Comae Date
13v signing this form,'hereby cerafp that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or io 151 IYCAC 02C.0100 or 15A NC 1C 02C.0200 Well Construction Standards and that a copy
0'this is a repair.fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair wider#21 remarks:section or on the back of this form.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: / 24.SUBMITTAL INSTRUCTIONS •
9.Total well depth below land surface: a 0 (ft.)
For multiple wells list all depths ifd different(example-3@200'and 2Q100) Submit this GW-1 within 30 days of well completion per the following:
1� 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: O (ft) Information Processing Unit,1617IMSC,Raleigh,NC 27699-1617
If water level is above casing.use"J+"
11.Borehole diameter: 1d (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Contml(IUC)
n n Program,1636 MSC,Raleigh,NCf27699-1636
12.Well construction method: (� dL D } ,S� 24c.For Water Supply and Open Loop GeothermalReturn Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.)
county environmental health department of the county where installed.
FOR WATER SUPPLY WELLS ONLY: • n 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
A 0 /`�(k Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) J Method of test: ddd 1
13b.Disinfection typellee M P--- Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018