GW1--02797_Well Construction - GW1_20240506

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor I ormation: AA ,
eff,ML ettt A ilGeL.
FROM TO DESCRIPTION
Weil/C� ct,//or Name A / t?c a (*l
mot' ) J� ft. C/f 1
c/{I1 ;
NC ell Contractor CertifcmionNumber l IS;OUTER CASING(forthulticdsed>wells)OR LINER(if sp llcabte): _ ',.'=:•:' .
FROM TO DIAMETER THICKNESS MATERIAL
Co ny Name l�� �/f) /J :^l6 INNER CASING.ORT[TBING(geottieial:dosed-lop)
2.Well Construction Permit : ��✓V v G ( FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State,Variance.etc) R' D' la.
3.Well Use(check well use): ft. to is
Water Supply Well: 1F•MT TO DIAMETER SLOT THICKNESS MATERIAL
Agricultural DM icipaUPublic it. it. in..
Geothermal(Heating/Cooling Supply) ffResidential Water Supply(single) tt ft. in.
Industrial/Commercial QResidential Water Supply(shared) ;I8::GROiIT t
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. ;'
Monitoring }Recovery ft. ft.
Injection Well: . ft. ft.
Aquifer Recharge QGmundwater Remediation
195 SAND/GRAVEL PACK(ifapplicable) _` -
Aquifer Storage and Recovery DSatinity Barrier FROM TO - )MATERIAL EMPLACEMENT METHOD
Aquifer Test - QStonnwater Drainage a ft- 3.9 ft bh,.'1jt..o.. bite—ll A..
Experimental Technology Subsidence Control ft. ft. �/
Geothermal(Closed Loop) DTracer 20 DRJLLINGLOG{attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRU ITON(color,hardness,sotUrozk type grain size etc.)
/ //' d ft* Yo ft* ie,�d c e/
4.Date Well(s)Completed: "/ "°i r Well ID# e/C9 ft. 5 7 D. � ,-2.....,, /`-e_—
• 5a.Well Location: d 2 ft' d e-9 ft. �''f�Y 7�‹
�
Ad,'/ G/3;sari7al ft. ft.
Facility/OwnerName Facility ID#(if applicable) R' D' i -
/��J 0.4 /
Physical Address,City,and Zip ft. -ft. E :L.C_ •E.i`i it I) -
27f j (9 21.REMARKS: MAY [ 24
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: u Q 3
�{^
(if well field,one lat/long is sufficient) ` 22.Certification:a(Q�y a-;A
wells Permanent or Ter o Si of Certified Well Contract& Date
6.Is(are)the () p racy I
� By signing this form.I hereby cert fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [JYes or 1j11`a with ISA NCAC 02C.0100 or 1SA NCAC 01C.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 tits record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. ,Site 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: (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths idif different(example-3@200'and 2^Q100') construction to the following: 1
10.Static water level below top of casing: ,J O (ft.) Division of Water Resources,Information Processing Unit, .
Ifwater level is above casing use"+" 1617 Mail Servi de Center,Raleigh,NC 27699 1617
+ ll
11.Borehole diameter: 1,9% On) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well con"s{raction method: a//7* �G _ / above,also submit one copy of this form within 30 days of completion of well
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 Servi i Center,Raleigh,NC 27699-1636 -
A
13a.Yield(gpm) 5-d i/'"1 Method of test: ` 11 \d\t\t-L\ 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also subtitit one copy of this form within 3,0 days of
13b.Disinfection type: h Amount: G�� completion of well construction io the county health department of the county
where constructed.
.......nm_, North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016