GW1--02420_Well Construction - GW1_20240422

WELL CONSTRUCTION RECORD(GW ll. For Internal Use Only:
1.Well Con r formation:
t !
/1 0bC t. R) 14WATERZANES 1
FROM TO DESCRIPTION
Weil Contractor Name ft. 1,(� ft. I
ccJ'(a It(gip 1 1
NC Well Contain C Number IS.: (for_ aedls)OR LINER-fir )
�- FROM TO DIAMETER THICIINESS MA L
Sys ,5 y R . 6, PVC .
Company Name J ,/ -16c.1NNER:CASlNG.3R;TUBING:( .dmed-leep)
2.Well Construction Permit#: / FROM DIAMETER THICKNESS MATERIAL
List all applicabk well conste on (Le C County,State.Variance.etc.) n7 /f(� I D.
3.Well Use(check well use): „ J �`
177..SCREEN'�' . . , '
I Ware ply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL -
Agncultural �M lie 0 ft 'u.
r (Heating/Cooling Supply) Residentiali�Water Supply(single) _ V A C ia, .
,
dust/al/Commercial °Residential Water Supply(shared) ..,ig GROUT: - '1
"Irrigation FROM TO MATERIA 1 EMPLA ENT METHOD& OUNT
Non-Water Supply Well: ft ( ® fz Ce 1-4` . -e L/n.. P/�d'
Monitoring E3Recovery - ft. ft.
Injection Well: ft. R
--- - -- -. Aquifer Recharge — .DGroundwater Remediation - -- 29.SAND/GRhVEl`l?AEHHfappficabk)•.
Aquifer Storage and Recovery ' 0 Salinity Barrier FROM 10 MATERIAL. EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft.
Experimental Technology °Subsidence Control Aif 0 (I1; .
Geothermal(Closed Loop) °Tracer 2e:1111IIUNG3 .(anaehadd L S ry)
Geothermal(Heating/Cooling ) Other(explain under#21 Remarks) FROM TO DESCRuF2 (con han�ts,=Wrecktype,gain sue,etc)
O ft.
Fly_ ftIc v is
. 4.Date Well(s)Completed: 9// 9 t??I( Well ID# tIS ft d 6.S^ //10 c--/4
•
5a. Location: _ft ft. 1..._7• ,. ;. . . . "' 1
ft ft . 6 `,,.,•nL..e ',°: t.
.Facility/ `Name Facility ID11(ifapplicablee)) I. APR 2 2 2024
- i
ft. ft ll4itl:7 M:r". .' r'.' ti.
grei-1,4' . (,),/e...-3-4-A Kell
'Physical City, Zip - - 1 rutlt--,PA rH;',..
�
LTA -
County Parcel Identification No.(PIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/lwg is sufficient) : : &
2.Certifi : a
i/•
W �7
6.Is(are)the wells) Permanent or °Temporary. Dare
By signing this form,I hereby cent that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or o with 1SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
[fats is a repair,fill out blown well construction information and explain the nature of the copy of this record has been provided to the well owner.
. .repair under s11 remark section or-on the back of t isfonn. - • . -- 23.Site diagram or additional well details: - S. N
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.
dulled: SUBMITTAL INSTRUCTIONS
9.Total well depthbelow land surface: ( d
(k) 24a. For All Wells: Submit this form within 30 days of completion of well
Fos multiple wells list all depths tfdj'enni(example-3@,200'�and/2(4�100) construction to the following: i •
• 10.Static water level blow top of casing: / (ft) Division of Water Resources,Information Processing Unit,
• If water level Is above casin&use"+,. 1617 Man Service Center,Raleigh,NC 27699-1617
11.Borehole diameter- C� (in-) +
( ) Z4b.For Infection Wells: In addition to sending the form to the address in 24a
ID.,P7above,also submit one copy of this form within 30'days of completion of well
12.Well constrnetion 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) C9 QJ Method of test: (�7 r 24c.For Water Supply&Injection 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: %/ Amount: r( completion.of well construction)to the county health department of the county
where constructed. I
Form GW-1 North Carolina Department of Enviionmental Quality-Division of Water Resources Revised 2-22-2016
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