GW1--02030_Well Construction - GW1_20240401

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: •
1.Well Contractor Information:
JGS' V 1` j 55 14:VVATERZON ?:=ES t r,.._..•§:t��:_r.„^�:`=+l..r �.kft . _ n'31s
Well Contractor Name r FROM TO DESCRIPTION
t [�i Dl ft. ft.
-1 i ft. ft. 1
NC Well Contractor Certification Number '.'15i OUTER CASING.(fo'r`.multi eased wells OR'TiTNER�(if ali liiii6le) �S-.t4:
t1(!' 1 ( !�\S'��\ �/L' i !t (I t `n) FROM
ft. TO
DIAMETERft. THICKNESS MATERIAL
`L fJ in.
Company Name
16-INNER.CAsnsTGOttTUBING:(iieatlieiiii0.losei14tbop) -TO :`;sl
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Count,State,Variance,etc.) 0 ft. ("3 S ft. U rra in c�f. ' (�. �-
3.Well Use(check well use): ft. ft. I in. 9"1/
17'SCREEN::#':.; , _ ....::' ,1u !„c, 1,.:.:fin t_' }, 2-1,,, _ _;
Water Supply Well:
FROM TO DIAMETER SLOT SIZE _ THICKNESS MATERIAL
Agricultural 0Municipal/Public ft. ft. in: 03 a 5c),
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) rt ft. in
I Industrial/Commercial OResidential Water Supply(shared) .8 GROUTr; :K .., 4 : tr.i. yr: am r.:.»w-M1.; X ,F.1ti;1 tili ' ;
Irrigation FROM TO MATERIAL _EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: b ft. g t; ft. 6,,,, 4- (JOB✓
Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge °Groundwater Remediation
.19.`sANDICI YYL',P.AGIG.(rf applicrible;)sfa s,.„ =gill?`EVii-a ::a—
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL(` EMPLACEMENT METHOD
Aquifer Test
Stonnwater Drainage •l'3 U ft. f 6 ft. 5,ewU flick."'
Experimental Technology Subsidence Control ft. . ft.
-6 -
Geothermal(ClosedLoop) Tracer -�2D':�I)RII;I;TNG%LOG"(eftechad'dials6eefaift%a¢eessoiyj, i"�� �` '�}s� fii'
Geothermal(Heating/Cooling Retum) Other(explain under#21 Remarks) -_FROM_ TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.L
- q pp ft. ft.
�`��
4.Date Well(s)Completed: t^a4 Well ID# Gil/0 k 6 ft. ft. ' 1:_ ; ^i 1 +ia�i >
5a.Well Location:
ft. ft. --L . a...LG i/
kkkr re(A ft. ft. APR d 1 624
Facility/Owner Name Facility ID#(if applicable) ft. rt. inlcrir,&,'iPa1 Pr(=nt;o gs;,9 um
3 0 INC--`30 b 5 g7 6406 rt. ft. UN;c;3:3;,
Physical Address, and Zip ft. ft.
y
O. SO rd'VREMARK.S.:Nz.N.i. n . fib. ,.>sa,xk' >;ih-rt :� mr:M,-' *.:.n,`,
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:
'S'S:'3140 C N `7 b y `SSX3d1 W 1 c
,� a- 5- y
6.Is(are)the well(s)tPermanent or ,Temporary Signature of Ce iced Well Co tractor. Date
Br signing this form,I here 1•cert j,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or 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 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
9.Total well depth below land surface: I b S (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: 7a. (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: //Z (in.) 24b.For Injection Wells: In addition to sending the fonn to the address in 24a
above, also submit one copy of'this fonn within 30 days of completion of well
12.Well construction method: . f�/ 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 m(gp ) -?? Method of test: a6i4 p 24c.For Water Supply& Injecti1on 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: .1-Ini Amount: S/t 5. 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