GW1--02027_Well Construction - GW1_20240401

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
i
1.Well Contractor Information:
ti- G 41 &fie5 14?:WATER,,ZONES Ra .i WW3 L r i s. . .:;.1 ,tt.: .1 :
FROM TO DESCRIPTION
Well Contractor 4ame { ft. ft. I '
4 v l 1 l(30 ft. %tJ 0ft. r vLte's�i2�-
0
NC Well Contractor Certification Number /� j 15.OU.TERCASING•(foi_'mulir rased wel[s):OR 1.1ZIERR(rf ap`licsble), ;�'�,{ua.`-fir
om ny 1.1� � 11 /C/1 I t( \PI
t 1 ( Li /' FROM TO DIAMETER THICKNESS MATERIAL
/• ► RA �'t/ V p J I l l.Ar� n. (�p ft. LI in- 5C) LI0 love_
CompanyName
16:INNERGASING:01MBIN ?(eotbei iil7claserl416 P)✓ j g.;
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) I S C ft. j 6 0 ft. , in. 5a LW PVC
3.Well Use(check well use): ft. f ft. in. 4
Water Supply Well: 17.SCREEN= ;:3 4 •. . - ..n.-r,.r,._ :._ a .;`
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public f bu ft. Ivo, ft. in o 02.D ). yv PVC
Geothermal(Heating/Cooling Supply) Rgesidential Water Supply(single) l ft. 7J it. in.
Industrial/Commercial *Residential Water Supply(shared) , 4 y_
1$.GROUT.... _ :"{:' r wr. ... ,� sn1.J'`a�•r'?•.".c�...r ;,r',
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: a ft. 9-4 ft. O,,�y.10ruk 1 � --p60 �
Monitoring Recovery ft. ft. Y�
Injection Well:
ft. ft.
Aquifer Recharge oGroundwater Remediation
19,SAND/GRAVEL PACK.(i1 aPPl cable). m., W, tw t ,'
Aquifer Storage and Recovery °Salinity Barrier FROM _ TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) °Tracer 20:;D1uI:LILVGtiOG;(aituch;ad+'d#ion`sllheetsiinecessszyy ; ° ;=.
Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION(color,hardness,soiUrock type,grain size.etc.)
(H g/ g ,°Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: '`.-.d`I Well ID# ft. ft. '
ft. ft.
5a.Well Location: .7_17_
671ki Ci &At� . /(� ft. ft. ( R '. {i :Fes'
Facility/Owner Name Facility ID#(if applicable) '\.,C D ft. air oft. C ;m.e.sie0e-
APR 2tlL
PP i I Pt). (g` lit_ 47gct ft. ft. A.
oss.,,,‘. �,'
Physical Address,City,and Zip ft. ft irt:S n n a n P ,X..�rl i W I
21REb1ARKS"`-, i;. r ,s;. .. :r._-,.;ter m,.t„ u�r4�,1?.rA. ,,.,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
IS.97SS42 N "?6.7S0'2. W 3-4-ay
6.Is(are)the well(s)ePermanent or Temporary Signat re of Certified e I Contractor Date
By si Wing this form, hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or efNo with 15A NCAC 02C.0100 or 1 JA 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 cop.,'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
f9.Total well depth below land surface: ifU (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: I7 (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: 7 t/a_ (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
J above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: t7 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c. For Water Sunnlv&Iniection 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: ' 1TH Amount: _ ., 1 65i 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