GW1--01877_Well Construction - GW1_20240322

rR, /6 Print Form
WELL CONSTRUCTION RECORD(GW 11) For Internal Use Only:
1.Well Contractor Informati n: t ��� �6ki- U(�4 Y'
6 ,1ait `'?{.,/7 if 14. ER ZONES
Weil Contractor Nafne "`��� FROM TO DESCRIPTION
ft. ft.
a L�! _ -- ft. ft. -.
NC Wellon:ractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
A/^ � ) ^�i 'A‘ FROM TO DIAMETER THICKNESS MATERIAL
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: _FROM TO DIAMETER I THICKNESS MATERIAL _
List all applicable well construction permits(i.e.VIC,County,State,Variance.etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
Water Agricultural OMunicipal/Public -1 7.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS A1:�Tt:KLV.
ft. ft. in.
Geothermal(Heating/Cooling Supply) D1 sidential Water Supply(single) ft. ft. in.
htdustriaiJCommercial Residential Water Supply(shared) 18.GROUT
Irrigation FROMTO M1f TERTAT.' EMI'j.AQF`MENx METHOD&AMOUNT
Non-Water Supply Well: ft. ft. 4; �; II^�'^
Monitoring Recovery ft. ft. t
Injection Well:
ift. ft. MAN 6 2024
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK ljfi;�pp}iepjlle);? ^^ Lp
Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL '.`J,,a,-,EMPLACEMENT ACEM1tENT METHOD _
Aquifer TestStormwater Drainage ft. ft.
Experimental Technology 0Stibsidence Control ft. ft.
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,Brain size,etc.)
j ft. ft. /�/G „/aC' //i C e'/
4.Date Well(s)Completed: /l P Well ID# . I ft. ft. 510a yt2NG_/ ^
5a.Well Location: I ft. It.L oil) �c s�"� 1 c)
li Ml� i� ft. ft. �� �` .
Facility/Owner Name Facility ID#(if applicable) ft. ft.
/
Physical Address;City,and Zip ft. ft.
4!" 21.REMARKS
,�/ ,J t �J 'l .A �r
County Parcel Identification No.(PIN) I o ,s' e /TAY,J l/z Q�J�" ta,'[�)L
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I! (is t!/Ai�4L 1) /0 '�©af ll- tTsz7
(if well field,one lat/long is sufficient) 2�ification:
34° ;0-T --) ,cV"N l22 W .5=/� /
6.Is(are)the well(s) crmanent or Temporary Signature ofCert'fed Well Contractor Date
By signing this form,1 hereby certify that the wall(s)was(were)constructed in accordance
7.Is this a repair to an existing well: es or ONo with ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,Jill nut known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#2l remarks section rr on the hack of this form.
23.Site diagram or additional well details:
3.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
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9.Total well depth below land surface: 7 Q _(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 d0'and 2 a.100') construction to the following:
10.Static water level below top of casing: /D[/ (ft.) Division of Water Resources,Information Processing Unit,
If Hater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection 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: A/ 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
1 L'
13a.Yield(gpm) . Method of test: �� r t 24c.For Water Supply&Injection Wells: In addition to sending the form to
//� the address(es) above, also submit one copy of this form within 30 days of
113b.Disinfection type: a) Amount:JL/J 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