GW1--01979_Well Construction - GW1_20240401

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: ,
1.Well Contractor Information:
I 1.7.........
Norris Justin Love i
Well Contractor Name FROM TO DESCRIPTION
NCWC-4081 C ft. ft.
ft. ft.
NC Well Contractor Certification Number
Love Well & Water Works, LLC IFROo.flateC SINCcfoThilIAMET llsYORIClNlz`(S hetble)r ... .:,-
FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 40 ft. 6 in.
Company Name
g141I1P1NERiC.;A;S NWOR?TUBING(`eotlieiviat closed<Itfoj►1. . ` s
2.Well Construction Permit#: • FROM TO DIAMETER THICKNESS MATERIAL r"
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft. 65 ft. 4 in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: t+17:;SCREEN" ' ` _— ' ,tI. 1.iiii.xm;, i a_.;: ;.:: '
H,,
1�A cultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
4� gn DMunicipal/Public 0 ft. ft. hi.
°Geothermal(Heating/Cooling Supply) x°Residential Water Supply(single)
ft. ft. ;n.
Industrial/Commercial
Residential Water Supply(shared)
Itti ati0n ltIGROUT 44, ,,,,, ,, r�. s "t"tn r � oww, `?
$ FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT'c
Non-Water Supply Well: ft. ft.
Monitoring Recovery ft. ft.
•
Injection Well:
- ---Aquifer Rech&ge --— __OGioundwater Remediation ft. fr. f — — —
�Aquifer Storage and Recovery Salini Barrier 197SA /G 1;'VEUPACI!(MATEiicable) ay .,,P _`i -;�
ty FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft.
__ Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) �gTracer M-
!� 1i20,1DRILL'A1G);QC..hail!itiditaillWreTiBl cisxar t) i; ,
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiUrock type,grain size,etc.)
ft. ft.
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
,,.-• .
Randall Medlin ft. ft. 1; Z i ,•h_o
Facility/Owner Name Facility ID#(if applicable) ft. ft.
8114 Morgan Mill Rd, Monroe NC 28110 ft. ft. �Pq ' 202
Physical Address,City,and Zip ft. ft. tfti%ZrT:S-.;g ar-
Union t 1 ��
08-012-001 G 215RE1+-ARKS'` .- 9-; _rjr,,,, ,4 -, ,u ,,n
County Parcel Identification No.(PIN) Relined casing to 65Ft
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/ong is sufficient) 22.Cer IIICation:
N W (-41...e' 3-4-24
6.Is(are)the well(s)Ox Permanent or Temporary Si tore of Certified 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: X°Yes or'ONo with 15A NCAC 02C.0100 or 15A 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 021 remarks section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only I 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: 165 (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.
If water level is above casing,use"+" ( ) Division of Water Resources,Inforroation Processing Unit,
1617 Mail Service!Center,Raleigh,NC 27699-1617
11.Borehole diameter:6
(1n.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: above, also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)20 Method of test: 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
13b.Disinfection type: Amount: completion of well construction!to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-20]6