GW1--02033_Well Construction - GW1_20240401

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:fi
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e�`J US V I y 5 . 14iNVATEICZO14ES. ', i',:" V.7 -01,;;W ..,4 a;,s.gt5.. rY': .,i`_�' .., •`_ a
Well Contractor Name FROM , TO DESCRIPTION
ft.-fi 7t ft.
ft. ft. •
NC Well Contractor Certification Number
15.OUTE&.CASING-(formulhat<il wells)'.OR liINER"(tf ap livable)"-��,�-?;r4 ,K',
t� 1 /v`� ���� /t� FROM TO DIAMETER THICKNESS MATERIAL
d- 1 f-'L (J I ft. ft. in.
Company Name
,l-,
':16r'INNER�GASINGOTUBING:(rieotlieruislclose3iUl} r t%';5 ,k^:
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
IList all applicable well construction permits(i.e.UIC,County;State,Variance,etc.) 0 ft. r 70 ft. L /j�in. ., J,. 17 f /J t
3.Well Use(check well use): ft. ft. 1 in. �C! t�
Water Supply Well: .17:--SCREENr.>.y. ,..'s ss_. r U:.;s e, _,..c:74: :`�1*.• r 4- tt.:,, s
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
*Agricultural DMunicipal/Public ' .7o ft. 900ft. c1� in. , 03a X t-(o !P(✓L
*Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
a ndustrial/Commercial OResidential Water Supply(shared) r, �.j ,F, 2 ,� 1• �r .xr e,
18:GROU1': ..,.. ....? f`.C��i ,.5�c'e�`r+.YfiX.. :�c s,.�"&'?r's ...��, �' .§,.
I IIIigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT 4
Non-Water Supply Well: 0 ft. 9 p ft. �jz,4 4, POvr/
'Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
',Aquifer Recharge 0Groundwater Remediation
.19 SAND%GRAYEIIP.AGK(tf applieable)r.:e;—,; 4 c"; .lei€
*Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
BE'A q u i fer Test 0 Stormwater Drainage l(s ft. ,9 co ft. # 3 5,..z !)OW
•:Experimental Technology OSubsidence Control ft. ft.
*:Geothermal(Closed Loop) Tracer ;2o`DRILLING I.OG`(aitacbsadifionalsheetsifnecessary},, :s;, ;.;?
Geothermal(Heating/Cooling Return) (explain #21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
( g/ g Other ex lain under ft. ft.
r� C A yam? +-
4.Date Well(s)Completed: Pi 3--9 Well no P J o i A ft. ft. .t, 1/4"r ;;J s�V�} r`)
5a.Well Location: ft, ft. ► b
{)c.J}tf i Q-A t S rt. a pp ft. L c uu s�o • ' 20Z�#
Facility/Owner Name Facility ID#(if applicable) ft. ft. 1�tL��' +Qt^i1 fir;^.� ,�
/530 1Lic 3065 g706 ft. ft.
Physical Address,City,and Zip ft. ft.
� ec,R0 :-Ii RE111AIllt.S'A. "* �ik—VO.,1 v ;M-44:4r
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
�(3rp( 22.Certification:
7S: 301 T7 N 76r '1,7 W
i6-aN
6.Is(are)the well(s)DPermanent or gi'emporary signatur of Ce tied Well Contractor Date
Br si ing t/r form,I hereby certifj'that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or •o with I yA 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 co/It of this record has been provided to the well owner.
repair under.-2J 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: e� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: p av (ft.) 24a. For All Wells: Submit his 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: (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: / �a (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: U '�� 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) 7 7 Method of test: ry 0"p 24c.For Water Supply&Injection Wells: In addition to sending the fonn to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: I-1TH Amount: S ibr, 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
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