GW1--02401_Well Construction - GW1_20240423

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only: iniMillan
1.Well Contractor Information: • ! •
1
•
Well Contractor Name nom nESCRIPITON
--.-- 4-__sf In,
i �. A ft. ft. 1
• NC Well Contractor Certification Number - ,,... _ . _ ,._.. ,
cA )tA C,�,\A-w e41 01b 1A-bh 1`ICY RO L) D ' THICK `„ 1/`�, .,, .
2. •
• �.
Construction Permit ` G_` . FROM .TO DIAMETER _ r rciciv S MATERIAL y
List all applicable well construction permits(i.e.UIC,County,State,Variance,eta) ft. in.
3.Well Use(check well use): ' ft. hL
Water Supply well: FROM . TO DIAMETER SLOT SIZE THICKNESS MATERIAL:
Agricultural DM blic ft, ft. in.
Geothermal(Heating/Cooling Supply) 'dential Water Supply(single) ft. ft. in.
Industrial/Commercial • DResidential Water Supply(shared) . - . ,• - . , t
Irrigation • FROM TO ( 6ee
/ATER,U,L p EMPiic- �Tl METHOD&AMOUNT
wan-water Supply Well: ti a� . - rt ` j e ��0 a ,i.
MonitoringRecovery ir. tit. h r.. E, .1'I., O W e^t J r
Injection Well: ft. ft. • 1
AquiferRecharge-- - - - QG oundwater Remediation
Aquifer Storage and Recovery I3Salinity Barrier ` FROM { O
TO MATERiAL - EMPLACEMENT
Aquifer Test QStomiwater Drainage . . ft. ft. .
I' Experimental Technology DSubsideace Control ft.
Geothermal(Closed Loop) DTracer µ:'.,
Geothermal(Heating/Cooling Reitim) [Other(explain under#21 Remarks) FROM TO DFSCRQ'r[ON Rolm'Yudnea,soNrock type,er to the edC.) •.
�A 0 f" .n �nreJ'--
4.Date Well(e)Completed: 0.11/o/Well ID!/ 9 •. • . ft. '^(1p-.../^4-
ft. ft,VI
sa.wen Loatiscee / / 44.0 ( "A�
(�17�C� s bon c• .
' Facility/OwnerN Facility DD#(if applicable) - 1 ft. ft. t 'b a.®.k,t L.a i. '+r. 1::::,i
1-i h s \-°`the - c► h �'VI- Me - ft' R APR 2 ;ti 20?4
PhysOA icalical A ,City,and 1 ,O / {,� n�,(' tl. it.
- ) ; -Y ..-D`.jc.l
County Parcel Identification No.(PIN) •
•
sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: . -
(ifwell field,one lat/long is sufficient) 22. t-- , i nation:
' i g5\-er*..AZ-A"-- y .., .
-' ,-, . if_
6.-Is(are)the well(a) ermanent or Temporary _T Fir- ►x„-,Well Contrscto; !
By ,> > : this form,I hereby certifj,that the waft)was O constructed in accordance
_ _- 7_Ia this a repair to an existing well: DYea or DIN • with 1SA NCAC 02C.0100 or 1SANCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,•ilioutbrmai wd l caudrtitlion iirfonmatien anderp/aii the nature ofilre FOPY Vali reeeidhes brenprovidead to the well owner-. - - --
repair under#21 remark 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 1 GW 1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: la _ �4UBMiTTAL INSTRUCTIONS
9.Total welldepth below land surface: a` (ft-) 24a.For All Wells* Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiferent(eranple-3(u�200'and 2Q100') construction to the•following:
10.Static water level below top of aV (ft.) Division of Water Resources,Information Processing Unit, •
filmier level is above casing,use" � 1617 Mall Servierf i
Center,Raleigh,NC 27699-1617
11.Borehole diameter: (In.) 24b•.For Infection Wells: In addition to sending the form to the address in 24a
12.Well comtrvctian method: '( above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,may,cable,direct push,etc.) construction to the following
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY S ONLY: • 1636 Mail Service Center,Raleigh,'NC 27699-1636
I• +
13a.Yidd(gpm)- - - Method of test 4 ` Me.For Water Suonly di Infectlan Wells: In addition to sending the form to
`1 ✓ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:• NZ� Amount: l'O "° ` completion of well construction to the county health department of the county
where constructed.•
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. Form GW-1 North Carolina Department of Enviromnental Quality-Division of Water Resources Revised 2-22 201d