GW1--01824_Well Construction - GW1_20240322

1.Well Contractor Information: J, '/), I y(t O • q I
0.4) 'Y tY. .9.Gl/ �l/./ .•14.:WATERZONFS'.',,.. F•:: •.,,;:t•. . :tZI.. —,., i!;s: . *.ti•°'. -.. .
Well Co trac rName j • FROM TO DESCRIPTItN
�1 i%)'l1�� y ft. ft. Ip nm „) ,�3 •) "
• ft. ft.
NC Well Contractor CertificA-llcation Number
L a 15O11TER:CASING(form`rilfiio3iidtielLs)ORLINERffs"licabie �-
_FROM TO DIAMETER THICKNESS MATERIAL
Company Name
16:INNER' LN 0 ft. (J/_ ft. • in: .32. k4i yi xji
CA5%((l
r G OR.+ IMIN :(ReuthifiallId'sedati f;5ArS3.V.1, %;:s: ;:tg;
2.Well Construction Permit if: J A y-4 FROM - TO DIAMETER . THICKNESS MATERIAL
Kist all applicable well construction permits(i.e.UIC,County.State.Variance,etc.) ft. it. In.
3.Well Use(check well use): ft. ft. In.
Water.Supply Well: 817.•SCREEN:::c...., : :Ot f"":ra.:::4.!<ttgiiS.2;}s::>t; .i:.:_Si{ -;Kli;c: .';; S:iia.,
FROM TOy DIAMETER SLOT SIZE +THICKNESS MATERIAL•
AgriculturalEICIlkipaUPUbliC • U ft. !t in. '
. Geothermal(Heating/Cooling Supply) DResidendal Water Supply(single) ft . ft in. -
Industrial/Commercial jResidential Water Supply(shared)
Irrigation ... 918rGROUTr.+}�:if.:'.:;.:;:+��.:f.;;=�:::a:.:: t�ie;4:::1�:-�'t:r rc,'is::ei1:::�i:��cr'r�7:;;�it',
FROM TO M4TERIAL TMVLACEMENTMETIIOD&AMOUNT
Non-Water Supply Well: R G^ ft:
Monitoring Recovery it: /� tt: 4t✓4 / �1�tt�
/r
Injection Well: !�J��l�T(rt / ��/.r
Aquifer Recharge �GroundwaterRemediation ft: ft. �j� S
AquiferStorageandRecovery Salini Barrier `19:SAND/GRAVEIrPACF:(ifapplicable) 'r :;c��:l u:. � ;::;}:=:_:r:•,;;?f:,
tY FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test • r3StonnwaterDrainage ft ft
Experimental Technology ID Subsidence Control it. • ft.
Geothermal(Closed Loop) Tracer •i20.�DRII:L'ING LOG(attach IIdditiuna11b2ets ifiieeess-lily)_es:w >::;.' i :: ;r's;•.:::
Geothermal(Heating/Cooling Return) (Other(explain under#21Remarks) OM TO DFSCRIP7ION(eafar.bardaesr.saYmektype,eear size,me.)
lift -o 1) " rt. I'v,.0 6%9I l
4.Date Well(s)ICompleted: Well ID# 7 ft. ,p.5 fe. V fry,1 L.r d'/V
MSa.WeellLocation: q �gP./51t et 4 ft 1 Li e./y t�1
A /L)1 .11llJ�( e.5 14'ft /t)®p ft. PiP✓/t .,.eld, /fd,i'%/r 9
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Faeilit�y/OwnerNa)m�e y -� Facility IDY(ifapplicable) it ft /a�4/ ) 5
s� •.
qt71!F )-)f e eri- (l�• )O lee/Y�' .57 ft. ft. [`
Physical Address.City,and Zip it ft. •
•
/I )L t it_ z21.•REHA►RKV,,..).U. ri*.V.': i; ir.'v;;;\:pp.•:;s'%r';';'^',�t:;:li ;.`•..:ria -,..-. ..
County . .PaccelIdentificationNo.(PIN) i�ds. °vn �� -^ i`:
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: • MAP y v 2021
(ifwell field,one latiloog is suMeicat) 22.Certification: _ •
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? r q c J�I��i N 79/ 1,/G; W /n�do, ,fir' :_-, -: ur
6.Is(are)the well(s) v Yermaneut or Temporary Signtureofeert166d Well Cent:actar Date
By signing this form,I hereby eerafy that the wells)was(were)constructed in accordance
7 Is this a repair to an existing well: DYes or No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards end that a
Ifthis is a repair.fill outlmmvn welt construction information and explain the nature of the cOpyOhh&record has been provided to the well owner.
repair under#21 remarks section or on the back of this farm. •
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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 TOTALNUMBER of wells construction details.You may also attach additional pages if necessary.
drilled:
? SUBMITTAL INSTRUCTIONS
9,Total well depth below land surface: 1 Pri 6) (ft) 24a.For MI Wells: Submit this form within 30 Formultlpfeweltslis:alldepthslfdlfferent(example.3(�200'and2@Joo' days of completion of well
r construction to thefollowing:
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10.Static water level below top of casing: ` (ft.) Division of Water Resources,Information Processing Unit,
lfwaterlevel is above caring use"+"
�� 1617 Mail Service Center;Raleigh,NC296991617
IL Borehole diameter: (in) 246.For Infection Welts: In addition to sending the form to the address in 24a
12.Well construction method: Y-Jt G- 1 / T above,also submit one copy of this form within 30 days of completion of well
(ie.augermtary,cable.direct push,etc.) Construction to the following:
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FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center;Raleigh,NC 27699-1636
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13a.Yield(gpm) I" Method of test:e//. L/ � 24c.For Water Supply&Infection Wells: In addition to sending the form to
j .the address(es) above, also submit one'-copy of this form within 30 days of
13b.Disialeetiontype: I Amount: �r^� Q� completion of'well construction to the county health department of the county
- where constructed.
Form GW-1 • North Carolina Department of Environmental Quality-Divisionof Water Resources Revised2-222016
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