GW1--01875_Well Construction - GW1_20240322

V''/e2,,2 Print Form
WELLCCrONSTRUCTION RECORD (GW-1) For Internal Use Onl
1.Wel �k= jlr� t
r �hr� /f 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
g P A xJt. (:,is ,ft. C_-P/v\
ft. ft.
NC ell Contractor Certification Number /! 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
h� Je Z n����`//) �' FROM TO DIAMETER THICKNESS MATERIAL
//r (� [ '��r� ft. ft. in.
Company Name
/ rDIAMETER
INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: S ,, ` FROM TO THICKNESS MATERIAL
List all applicable well construction permits(i.e.UI ,County,State,Variance,etc.) 6: ft. 4/3 ft. C �,77 in. , ./) // _
3.Well Use(check well use): ft. ft. in. ✓ T I�
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAI.
Agricultu.al 0M icipal/Public it. it. in.
Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) H. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MAT ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. cg / ft. /,_4/70,Ja'--��- Azof-ly �QIL.,
MonitoringRecovery ft. ft. �X `� c�<�,C
Injection Well: ft. ft. ._.)'-
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery [Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stotmwater Drainage
ft. It.
Experimental Technology Q subsidence Control ft. ft.
Geothermal(Closed Loop) 0 Tracer 20.DRILLING LOG(attach additional sheets If necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) ft. / ft. Q 2 b
v G /,
Q
4.Date Well(s)Completed:..-?/�` ( aY Well ID# V/p\2a / y ft. 090 R. /./1/ L( R. ..
5a.Well Location: a U ft. 1 3 ft. f�' 1/l/i h
/OM �`l Z-1 5 e,0/1 L 493aoo,f V7/ 113 f t. 6206r. a-a 4N i',"�
Facility/Owner Name Facility ID#(if applicable)
9i7,2- Aid 1A/r/rl/ LK /Il "ako�/ ft- ft. IN. _Pt.:;`�r1= '
Physical Address,City,and Zip ft. ft. (')
4 /!`nY 21.REMARKS ,' t2 G [V
County Parcel Identification No.(PIN) F
ITN:.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: u
(if well field,one lat/long is sufficient) 0 22.�tifieation: `
w i"'7,,/
6.Is(are)the well(s) ermanent or OTemporary Signature of C ified 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 Fes° 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:
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 TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1001arG�f' (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(examp e-3@200'a t 2@100) construction to the following:
10.Static water level below top of casing: AO (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" Li 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 / [J (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: Al)2 PU/de s/ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
24c.For Water Supply IniectionWells: In a
13a.Yield(gpm) Method of test: f'/n�T & ddition to sending 2 ��� the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:;k/kD'tfAe.--- Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016