GW1--02028_Well Construction - GW1_20240401

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: .. ��
1.Well Contractor Information: 1
oS~t Rev 2l$ la.waTER^zolvEs. . - �:=�s, ,_ ...v. . . ..�_�. g.-� . ,;10',,,,":F.>
Well Contractor Name (/ FROM TO DESCRIPTION
/ ft. ft.
I'�� {i r t ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased wellsyOR LINER'(if ap`liable)A
tn/1 140
IU l� n�f I Ir I / FROM TO DIAMETER THICKNESS MATERIAL
UV 1 I"� f! 1✓ l�C/ ft. ft. i in.
Company Name
'16.INNERCASINGQR>TUBING;(Qeotbeimal'dosed4u6OI,r: ?k _ v!
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) D ft. og g r1¢ft. Li, in. $' i
,4O love-
3.Well Use(check well use): ft. d O ft. in. 7
Water Supply Well: 17.:SCREEN.r,•.'. r:-.C%t.ir',.7x +.:: ._..:,. _,., x;:"F:;iffri.;:." K:,�>
FROM TO _ DIAMETER SLOT SIZE THICKNESS MATERIAL
*Agricultural OMunicipal/Public , ft. �15g ft. 1 tn. 0P0 S- O f1 e—
a� � C •� D'V
i] Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
l
i Industrial/Commercial !jiResidential Water Supply(shared)
18:GROUT -_'�'' .'A.:_.�k.r,.+.'i' ::Xt?+,f,`.v,-fgAIs 7Z_1c•Wlik :. ':
I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
*iMonitoring ORecovery ft. ft.
Injection Well:
ft. ft.
*Aquifer Recharge (*!Groundwater Remediation •
19.SAND/GR 1VELTACK(da{ipGcablel It a' ,ti.4/)/.,..i' y t ,,:_ .,s
It Aquifer Storage and Recovery 01Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
OlAquifer Test EtStormwater Drainage ft. ft.
*Experimental Technology 0Subsidence Control ft. ft.
',Geothermal(Closed Loop) OTracer '26 DRII,LING;LOG(attnclt additiobal sheets if neeeseairy)j i #: -:.n Zfi ,?.
�0:Geothermal(Heating/Cooling Return) ij i Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
ft. ft. 1-
4.Date Well(s)Completed: 3—r 4—a Li Well ID# ft. ft. ` , ,!‘ f ra-
5a.Well Location: ft. ft. '
Te& .- IA EsSeLtc)el - ft. ft. ��'!? 1 2024
V�.
Facility/Owner Name ` i�(I /n� acility ID#(riff applicable)/ ,nt'U!l ft. ,p g' fL �j�(/Lte St0(i;e i{^�„'.;z n;fir-.�.sa r. „,ug1
. 11503 U.l , C2( i c., tvc- ' ft. J ft. •
L'r� 'G'
Physical Address,City,and Zip O ft. ft.
Pei LSO ir ,21`REMA/IRSS'A. 4i: 1.0 T*r'::...,n''r.'�i:.� .x. :4iM..; 8k. •t;u;Ys•-+
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(if well field,one latilong is sufficient) 22.Certification:
S. S77GS N 76. 0577 W
3-1b"
6.Is(are)the well(s)>JPermanent or Temporary Signature f Ce red Well Contractor' Date
By signi g this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or 121<o 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 cops•of this record has been provided to the well owner.
repair under r21 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: .(�� (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: IS (ft.) i
Division of R ater Resources,Information Processing Unit,
If water level is above casing,use"—', f t 1617 Mail Service;Center,Raleigh,NC 27699-1617
11.Borehole diameter: / /a (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
f�1 above, also submit one copy of;this form within 30 days of completion of well
12.Well construction method:' 0 (( 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) Method of test: 24c.For Water Supply&Iniection Wells: In addition to sending the form to
I the address(es) above, also submit one copy of this fonn within 30 days of
13b.Disinfection type: J'iyH Amount: I 10. 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