GW1--01988_Well Construction - GW1_20240401

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
1 1 :
-7 r,t nel i ccr t.. a—) 14.WATER ZONES t ,,.
Well Contractor Name FROM TO DESCRIPTION
40G3_ 0 ft. 170 ft. .4i,(lc)4..3
"L I ft. ft.
NC Well Contractor Certification Number .--15.•OUTER CASING(formulti-cnecd--vdln)}OR-LINER(ifnp ncoble) - ---•-------
/�_ \Q ( _ _y ) 'n FROM TO DIAMETER THICKNESS MATERIAL
.tf O �{/l W- ft. ft. in.
Company Name
/�,.. 16.INNER CASING OR TUBING'(geothermal closed-loop)_ - - •
2.Well Construction Permit#:0... �'° 2623- /36Z- FROM TO . DIAMETER . THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 6 ft. I l V ' ft. /_,ZS- in' 5-bJItIG G Z 1 p vC
3.Well Use(check well use): ft ft. vv
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
®Agricultural OM cipal/Public ft. ft. in.
®Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
1.
111iIndustrial/Commercial DResidential Water Supply(shared) 18.GROUT '
iIrrigation • FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: a ft. 'd ft. $ttolwk PU��
cw
"Monitoring Recovery ft. ft. �
Injection Well: - -_ •
-
ft. ft.
"Aquifer Recharge D Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
ViAquifer Storage and Recovery (Salinity Bather FROM TO MATERIAL EMPLACEMENT METHOD
"Aquifer Test E3 Stormwater Drainage ft. ft.
"Experimental Technology 0Subsidence Control ft. ft.
"Geothermal(Closed Loop) 0ITracer 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.)
C? ft. 110 ft. CI0.y f Cite-YID w- A..
4.Date Well(s)Completed: 11�I b Z� Well ID# I/0 ft. 3o r ft, CI rGth.k
5a.Well Location: ft, '
ER;c. S tin 19ra phoi11Q II. ft. • {�1 ;,,� J -1—)
Facility/Owner Name Facility ID#(if applicable) ft. D. , 'k.Via. 4,.,e L.Y. I .b.3
•
4
Z '1 T ISLlrne i/c-t Rol, µe S'h�P,1�)L- 8742 ft. ft. APR 1 CGZ
Physical Address,City,and Zip, ft. ft.
""ge-i1d-Dircor 952I 50/..1 21.REMARKS. ' . ' .lli 1 i dor 4-5 .. .. .
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification: '
35°20' 3d.gzol df ''N Sz°3 ' IV.(12-9 G 10" w �, 3')9 et'
6.Is(are)the well(s) Permanent or Temporary gnature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is thisi repair to an existing well: [JYes or ONO with 15A NCAC 02C.0100 or I5A 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: 305 T'� (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: i •
10.Static water level below top of casing: 'TU ' (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617 - '
11.Borehole diameter: (0•2-fr- (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: Ao-r-cuty 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
13a.Yield(gpm) I c Method of test: at. comml .d.-24c.For Water Supply&Iniection Wells: In addition to sending the form to
�" 11 . the address(es) above, also submit'one copy of this form within 30 days of
13b.Disinfection type: C, �01/11 e. Amount: TA, 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 2-22-2016