GW1--02665_Well Construction - GW1_20240501

WELL CONSTRUCTION RECORD (GW-1) For Internal Use'Only:
1.Well Contractor Information:
.14.WATER ZONES - ' ' ' '
�Iv�l.ctcvt �,. �ccs� -
Well Contractor Name FROM TO DESCRIPTION
j� 0 ft. ./art. it t
IO9 3 --rl ft. ft. 1 1
NC Well Contractor Certification Number --15.OUTER CASING(tor multi-cased-wefts)OR-LINER-(ifapFIicable)- -- --- --
I
��j
trl� �^ (���� FROM TO DIAMETER THICKNESS MATERIAL
l� J ft. ft. 1 in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: ac3•2 3 -C20 3 l FROM TO D ,'T`E THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 R. 3 rIAME 0IL _ 'y• 2 _R. 1n- s b"/2 I. v C5
3.Well Use(check well use): ft. ft.
Water Supply Well: FROM REE TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
Agricultural OM 'cipal/Public ft. it. 1n•
Geothermal(Heating/Cooling Supply) C •esidential Water Supply(single) ft. ft. in•I
Industrial/Commercial Residential Water Supply(shared) 19.GROUT
Irrigation FROM TO MATERIALEMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. ft. &ka eet4L
Monitoring ( Recovery ft. ft. CAA AI r
Injection Well: "�""r
� ft. ft.
Aquifer Recharge
.•-... Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test EtStormwater Drainage ft. n•
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) O
Tracer Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) 20.DRILLING'LOG(attach additional sheets if necessary) ,' ' ' .
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
''JJ 0 ft. 3o ft- Clvl / N uM.Ux
4.Date Well(s)Completed: '1')9'14. Well ID# 30 ft' $brit GlrOJA,11--e.-
5a.Well Location: ft. ft.
/��� n �l D ft. ft. t,,M.`_.F li t,la�
Facility/OwnsJName'`\ Facility ID#(if applicable) ft.ni
ft. MAY q) 1 2021
. 1 11.1 ictlt3 1 gltxamt.ux t .lS"la� ft, ft
Ph ical Address,City,and Zipft. ft. 11'rai:ii 1Z41^it ;`'i-'.� sr.,i.,, U.
lJ '1 Alai- 7.-..J
b �'611rJe-. 11' I-bti q,1t 0 a .21_REMARKS -
County Parcel Identification No.(PIN) _ ... .
1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.
e 144 454• "SSliv g2° 3s'' A,. $'G 2? q4 4 W
v'- t{- 1 q 2 ki
- 6.Is(are)the well(s) Permanent or Temporary Si tre of Certified Well r Date
By signing this form,I hereby certifi,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or 1No with 15A 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 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: Sam (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@I2-00'and 2@100') construction to the following: i
10.Static water level below top of casing: I_V V (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: ,l. 2 r" (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: ROI 0 yi�� above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 1 W t 1"`"// 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: �r (� ,,,, 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) U Method of test:3 al- l.CIni p ly-24c.For Water Supply&Infection Wells: In addition to sending the form to
u ,' the address(es) above, also submit one copy of this form within 30 days of
On 13b.Disinfection type: 'lt}Y11 ei Amount: g "6-19-1
1&-' 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 Resouri esI - Revised 2-22-2016