GW1--01553_Well Construction - GW1_20240308

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
��(`1 R. ge)�1e-- 14.WATER ZONES
Well Contra torName FROM TO DESCRIPTION
PI f � r
3� . 'Z ►V.%
3s 41
NC Well Contractor Certification Number 15.OUTER CASING(for multi-ca led wells)OR LINER(if ap liable)
l 1 4 t 1-\��� t I I `� 1 FROM TO DIAMETER THICKNESS MA5E12
i� 6 (� ` 4- D 11 I R_ �)It'in. AOdI I[) Y�l
Company Name 1 It t 1 I 1 g v!4 �'dea- ,0 al V+ t•v^.�i-,._'
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 3 q 3 %S 3 FROM TO DIAMETER THICIt1NESS MATERIAL
List all applicable well construction permits(i.e.UIC.County.State.Variance etc.) tt• ft. in.
3.Well Use(check well use): tr ft. in.
W
17.SCREEN /J(>�
ater Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural �❑Municipal/Public ft. in.
❑Geothermal(Heating/Cooling Supply) t�Residential Water Supply(single) R. 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: O ft- 3 ft. ex.w: p t,0w1e4
❑Monitoring ❑Recovery 3 ftito ft. > .(v� � � �e�
Injection Well: ft it. r1,
❑Aquifer Recharge ❑Groundwater Remediation
❑A uifer Storage and Recovery ❑Salini Barrier 19.SAND/GRAVEL PACK(if applicable)Ai UP
q g tYFROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft. '
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Gcothetmal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type,grain size,etc.)
_ f 0 ft' H'
.4o 1 I �r9 S e-t 1 - - -
4.Date Well(s)Completed:O AO � iD#Well 3 %b 3 t_t3U ft. (0 ft. 1M 1::)‘(51- 5p-1 i `
5a.Well Location: (�0 ft.. 1,l S. it Cfrirkeit-AA R1,
.� a°S 7-9�',h,Curl I IS it 3(c ft [i��I�.� 5ra�► --te _ ,-....
Facility/OwnerName Facility 1D#(if applicable) - . - n r ,r, Li
ft.J I \ ft. ft.
`J $9 I � 1 S?,::- ��i rlO SS NPh(kQ►2g�11 TV O' x-16 ft. it IVI kt [j v Lip
Physical Address,Citynd Zip /
U �� QL _ ©1 0-0b 21.REMARKS , ?. r..,,R, 'tll 1.:.74
County Parcel Identification No.(PIN) Illicit 0
T1+Lirt
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C tiftcation-
i
•
3b. \ ( 30 N '��C, ack ) 3 w /� , ©� kgid,0,4
ar thell r 565nature o f ertifie Well Contracto Date
i 6.Is(are) we (s): .e manent or ❑Temporary
By signing this form,I hereby certij+thnt the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or "o I5A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If 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 under#21 remark 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 I 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: ,3 2 5 (ft.)
For multiple wells list all depths iifdii different(example-3@200'and 2 n 100) Submit this GW-1 within 30 days of well completion per the following: •
10.Static water level below top of casing: Cn 24a. For All Wells: Original form to Division of Water Resources (DWR),
(ftInformation Processing-Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+•'
11.Borehole diameter: L (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Pt-i d2 R0-T-40 24c.For Water Supply and Open-Loop Geothermal Return 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: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
n Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: B'(l8
13b.Disinfection type: y[t(0 A(0 r !r d_Amount: \ r ?-
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resourc i Revised 6-6-2018