GW1--01874_Well Construction - GW1_20240322

IL' /( Print Form
WELL CONSTRUCTION RECORD(GW- F r int al se On y:
1.\ I Contractor Information: I � �� -1 \� / `1v(el lU I I 1 u l
& 7,k SAett' ll 14.WATER ZONES
FROM TO
Well Contractor Name DESCRIPTION
IPPTIION
T ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
/ -ie /l^ '/7/ A� FROM TO DIAMETER THICKNESS MATERI U: .
A' /1 r7 f /Y�li ft, ft. in.
Company Name p 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: O� ! gr.. FROM TO DIAMETER , THICKNESS MATERIAL
List all applicable well construction permits(i.e. C,County,State,Variance,etc.) Q ft. !�J ft. / in. lg? p ..4.
3.Well Use(check well use): ft. ft. in. v
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural °Municipal/Public rt. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) rt. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL / EMPLACEMENT DIE"THOU&/AMOUNT
Non-Wate,-Supply Well: © ft. /J 2 ft. n��//�Jl./y[7 /��/,j�,� �LOG(�
Monitoring Recovery ft. d�/ ft. �3
Injection Well:
ft. ft.
Aquifer Recharge °Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO SU'rERIAL EMPLACEMENT METHOD
Aquifer Test °Stormwater Drainage ft. ft.
Experimental Technology °Subsidence Control ft. It.
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) [Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
4.Date Well(s)Completed:3--i-7 dr Well ID# / �ft. ` 7 rt. �v � v���
/7 �6 t�� pv�/, ,-
Sa.Well Location: 6 �ft. !3 ft. rt�4�4 e"
' I/y 1)r Ri!/ZI27f /p3O OD//QS�,�� ft. "f6D ft. L��/L�; _ _ �1._.�
acility/Owt(er Name Facility ID#(if applicable) ft. `� ft. i_`i t 'F.I j �,.i)
6 C ,I rSLm 1� I/O o n ft. ft.
�.f
Physical Address,City,andZip ft. ft. MAli 2 2 2074
_
21.REMARKS
/ve,e✓ IITiv;,-Ki.';1 `�•. .7�tv;;;+6 tjn'1
'County / Parcel Identification No.(PIN) i.:W(;"y'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cer ification:
.3g il,ta`d' t 2%1N eiz'G� 4� Gflo� W f)&1/11,/� -l`��`�
6.Is(are)the well(sl ermanent or °Teneporary Signature of Certif d Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or KO with ISA NCAC 02C.0100 or ISA 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#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 site details or well
construction,only 1 GW-1 is needed. Irdicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: . SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: D a (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
i
11.Borehole diameter: h ` e (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method:1}.n /S 6T C}'A">/ construction to the following:
(i.e.auger,rotary,cable,direct push, ic.)
- Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) f'0 Method of test: I . /P-74 24c.For Water Supply&Infection Wells: In addition to sending the form to
'A( Q / the address(es) above, also submit one copy of this form within 30 days of
I
13b.Disinfection type:( lU(0 Yb✓ Amount: it c 0 7 completion of well construction to the county health department of the county
i where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016