GW1--02475_Well Construction - GW1_20240423

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WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1.Well ontractor Information
a-r relr PQ.-� 611— = i:; w ;�l r-.-�.1t lr„ : :' . . ._
FROM TO DESCRIPTION
Well Contractor Name • ft. ft.
6 1 i-A ft, ft.
NC Well Contractor Certification Number /� ///��} ;,�1S;j�;Tj6?Eft; r�'1§I l ;(rireintil((7C'e iatf t)11) A'.tai iiigleit ftioti :;:;:••,
/' 'r ��) 'lamp ' �1A I FROM TOft. rt. DIAMETER THICKNESS MATERIAL
Company Nam /�� 45:1I 1NT WOWSINWOR 7![JBfP,YZ7;'(i dilieliokltilleie3kCti:lirii::"`:^rs. ;
2.Well Construction Permit#: 6 e 0 e!r Ma) FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well connstruction permits(i.e.UIC,County,State,Variance,etc.)
ft. R. ' In.
ft. ft. 1 In.
3.Well Use(check well use): -
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public ft. ft. 1 in.
eothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. ! I in, .
Water Supply shared ,as �;:>,:' .(•;;# s; :>` .
Industrial/Commercial Residential PPY( ) '�tllii?b�RQC1�:..:,r,;�•;.:<��'i;<:F:<,,:•:��i;� a �::::.• `?5�'� . :•�.••'�; -,•:
Irrigation . FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: rt. ft.
Monitoring ' - DRecovery ft. • ft.
injection Well: f6 ft.
Aquifer Recharge jlll Groundwater Remediation , 1.97.00D/t RAAEliOMIOlft pplleiiii1W—• W ; ;.' 4 '.•1-•. •• `•'
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test '. `', DStormwater Drainage ft• ft.
Experimental Technology „.: .,•'.',.., Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer '`:YOB,b'Ittitlul l•Gtf:d.Yp4(att8tiff'Atifii:Ab$`elttilieeteIffWeikei )^_,i,•4:z ':•:.:'
FROM TO DESCRIPTION(color,bordness,soll/rack type,grain Axe,etc.)
,,.. Geothermal(Heating/Cooling Return) y Other(explain under#21 Remarks) ft. ft. i
4.Date Well(s)Com ✓pleted: - -6C- Well ID# ft• ft. ! r-^ ,� ^`•--_,,
ft. • ft. I' f b L.is 5i l,-
Sa.Well Laeatlolt/ ///Q-!� Nak• ft. ft.G /J ?G?4 APR 2 :
Facility/Owner Name Facility ID if applicable) ft. ft.
ft. ft. lfi a:,: . a,,.
' )35-7 rr8-en/k/fLY4-0-it)/A- • Kd
•
Physical dress ty,and Zi I ft. ft. I
der r l •-tort)vtt►os .._,.,.'sf f , ,,.1 43. . .s.
County Parcel identification,No.(PiN)- •-• '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degreesi •
(if well field,one ladlong is sufficient) 22.Certification:
05.956W 11
0 7 N —82. 34 a53 w s �y-v4f)//TPR,71 .. S 0
t Signetu[eefCertified Well Contractor Date
6.Is(are)the well(s) ermanent dr OTemporary t
By signing this form.I hereby tcerl/jy that the well(s)was(were)constructed to accordance
7.Is this a repair to an existing.well:- DYes -or No - with ISA NCAC 02C.0100 or iJA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair, ill out known well eopstructlon Information an explain the nature of the copy of this record has been provided to the well owner.
repair under 1121 reiimt_kssection or on the back ofihis 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,onlconstruction details. You may.also attach additional pages if necessary.
y,l GW.-1 is needed. Indicate TOTALNUMBER of wells
drilled: Lt.- I SUBMITTAL INSTRUCTIONS
9.Total well depth below land'surface: d g'�'5-6 ta Joe (ft•) 24a.j'or All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(fdiferent(example-3@200'and 2@100) construction to the following:::
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: Co / (in.) 24b.For Injection Well 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: ro (—N}" 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 Mali Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c,For Water Supnlv&Intection 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: completion of well constkwtion to the county health department of the county
where constructed.
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22.2016