GW1--02029_Well Construction - GW1_20240401

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: ,
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Well ContractorName FROM TO DESCRIPTION
L I c1 - ft. ft
ft. ft
NC Well Contractor Certification Number
rri5:iOUTER'CA.S1N( {itii�iirisieliieeli)tigailitidi!lQt' '"`bibs'-t +?A>
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' FROMft. TO DIAMETER THICKNESS MATERIAL
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Company Name
rlt:INNER C4.-SING OB TIngelagiii irp `Weti-S a : ^3
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS
SS7 MATERIAL
List all applicable well construction permits(i.e.UIC,County State,Variance.etc.) D n' )3 5 n- t11 cif;( / pvC_
3.Well Use(check well use): R n. "I'
Water Supply Well: - 17FSCREYN c:4- - !^ # :,6^i C�^ :: r,A` gi 1'fiilz. € y::
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
*Agricultural 0Municipal/Public 135 n. 165 n- 1 in. e n3o c. Li ,/)„Vc.
[ ,Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. n. in. /
r.I ndustrial/Commercial OResidential Water Supply(shared)
fJl&'GROII1'€.'''w ' `i ..w.�si�a� ✓r,.t:`a t[Mt�rla+ssf�6-.'k'rsr�'.N£�m,:
%Irritation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: b n- co n. `(i-Avi--,, eck,c
(Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
It Aquifer Recharge OGroundwater Remediation
::719.7SANDIGRIVELPACIC ftfsPitlieatite)±b+ 'z AWAi*4tIfiV4^ M
%1Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
*Aquifer Test 0Stormwater Drainage (3 0 ft. I b s ft. .1t+ 7 cett( (Pes r
j�Experimental Technology Subsidence Control ft. ft. +
%Geothermal(Closed Loop) DTracer 20:iti111110tG LOG1(attiie.h udd➢tioi alsf ee0ifaeeessaiy) tl
ij�'i Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
( g/ g Other(explain under#_1 Remarks) ft. ft.
4.Date Well(s)Completed:P-(6-Q Li Well ID# 1(3) (rt✓0( 4 ft. It. l Y .(`' -... r� ;4
5a.Well Location:
ft. ft. I
ft. ft. APR d i2E4
Facility/Owner Name j Facility ID#(if applicable) ft. ft. 1!t urir h%{e I Y uc
i 5.3 0 ( "AO(' 5 77(t30 V ft. ft. DkiliCtIZOG
Physical Address,City,and Zip ft. ft.
0 e CI 'co 21:,REMi 5,:v.: 4'Ait..V,<V•ii'T'9ns'IS u 'tit'^? ;tct..•.g p, M 4eer' *i
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: i
' "3S. 31`b3 b N `-)b, c35a3y w LG I; g-/5-0(1
6.Is(are)the well(s)O(Permanent or Temporary Signature of Ce ted Well Cont ctor Date
Br signing this form.I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ID Yes or 'No with I SA NCAC 02C.0100 or I SA 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 tnay also attach additional pages if necessary.
drilled: r SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 I� (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: --2r (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
/// It 1
11.Borehole diameter: a (in.) 24b.For Infection Wells: In addition to sending the fonn to the address in 24a
,p above, also submit one copy of;this fonn within 30 days of completion of well
12.Well construction method: f\t�"ltir y construction to the following: ;(i.e.auger,rotary,cable,direct push,etc.) l .
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ?"2 f�Method of test: (Ld%t f2 24c.For Water Supply& Iniection Wells: In addition to sending the form to
C the address(es) above, also submit one copy of this form within 30 days of
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13b.Disinfection type: 1-'l111 Amount: S I V 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 Resou ces Revised 2-22-2016