GW1--02632_Well Construction - GW1_20240501

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: '
1.Well Contractor Information:
J1CS scrn. (5)i hs '=1a:.WATER-ZONES ,-r:_ : <,' . : . -- . - ,
Well Contractor Name FROM TO DESCR�IPTION
�D t v 11. Ft ft f�TUtiov
ft. t(3-'p ft- I 1'le.L.J
NC well Contractor Certification Number =15::OUTERCABING(foriiialti=mi6a',iThrOR-LINER-(iCnp'"nmble)==---- L=--
i,6� ry V` f /j �• FROM ft. TO ft. DIAMETER in. THICKNESS MATERIAL
Company Name L
l '"l(l 1 / ,.16:INNER CASING OR TUBING(geatherriial closed loon)-'_-: .--_-1- ... -.'-: .
2.Well Construction Permit#: 4015 `I —1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County,State,Variance,etc.) t.) ft. 0 - ft. (0 2- in. SOnz/ pt/e
3.Well Use(check well use): ft.
lY In.
l
Water Supply Well: `i9•SCREEN.'14:i .:"-: : .; . -; -:--. :i;;: , _.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
*Agricultural OM •'cipal/Public rt. ft. I in.
fill Geothermal(Heating/Cooling Supply) la.esidential Water Supply(single) ft. ft.
a Industrial/Commercial OResidential Water Supply(shared) --
..18.,GROUT`-`'.: ;:::,__=:"; .,. i.- - - - -
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft d-0 ft. ILK ttWif Po u
*Monitoring EiRecovery ft. ft. y
Injection Well: ft. ft. 'J
*Aquifer Recharge (Groundwater Remediation -
19.'SAND/GRAVEL PACK(if applicable). .----:--:`;--=_: -2-:. -
$1 Aquifer Storage and Recovery 0Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
*Aquifer Test OStormwater Drainage ft. ft.
®'Experimental Technology DISubsidence Control ft ft.
j Geothermal(Closed Loop) [Tracer -.,-,,. 20.DRILLING:LOG'(attach additional sheets niecessliy) : .
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) . 3v a. Cl0.D )t'!O Ut.tr b W-c1...011--N
4.Date Well(s)Completed: 31 I 24 Well ID# 3 0 ft G f g° ft a MIA r`i—e--
ft ft.
5aa.,Well Location:g _
%
Facility/Owner-Warne Facility]D#(if applicable) ft. ft
ft. ft. MAY C(JC4
S34 69P'l'ersbu Mit PA , ► a.vci-aik, iVC_ Zg7S3t
Physical Address,City,and Zip J ft. ft. IPfi.n -,r:1 ?.----:;,:z:,-.a,1r,
Ma d L291 q7Zi^ f-q5_l/g .21s_REMARKS =.,-,:,_ s---7 _-. .. ' ...Vis:Q. h=,' ....-. ._ -,
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:
829�Z ° �'
35. N g2 :. L 1 l 1 w . z.ct 2-1-1
6.Is(are)the well(s)a'ermanent or EITemporary ignanue of ertified Well Contractor ate
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: (jYes or _ o with 15ANCAC 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 copy 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: LI 41) (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
Formultiple wells list all depths if different(example-3@200'and 2Qa 100') construction to the following:
10.Static water level below top of casing: -6 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (p.2 C (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: i^`' p above,also submit one copy of,this form within 30 days of completion of well
construction to the following: i
(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) OD Method of test:S9A t C'o�ni-iin21L 24c.For Water Sunnly&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:(/k\OY i 4 Amount: 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