GW1--02828_Well Construction - GW1_20240506

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
. c l e se + 14. Y .
x a
• FROM TO DESCRIPTIONWelll Contractor Name
Ll( t I i6(4 ft, a b O ft. 1-11&ylC Sr
ft. ft. i d v e-
NC Well Contractor Certification Number 15.'OUTERCASING(for iiiulh-cased well`s)OR,LINER'(ifap`heable)'
"� ��n j 1� / FROM TO DIAMETER THICKN�EESS 'MATERIAL
�l Y yName f 4lI' l�t,�� • ft. ft. �b in. .3 /5 C I
Company Name ar
.'16."INNERCASING:Y)R:TUBING;'(geotbeiinalcloseli-loop) .Iglx r�..
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.LUC,County,State,Variance,etc.) 0 ft.
I/_O p ft. n O in. t 3 7[J J�+ lee.'
3.Well Use(check well use): ft. b ft.
O in.
Water Supply Well 17c SCREEN ! -t =r. t " .:=
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft.
Industrial/Commercial /�� Residential Water Supply(shared) is.GROUT a: as ?:
Irrigation (:J2 yVi� f FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 111 ft• v IL ��` r��,01)C
!Monitoring Recovery f l(g ft. ft. c P`V tM C�/�tCw
Injection Well: ft. ft.Aquifer Recharge - Groundwater Remediation
19 SAND/GRAVEL,EAGK(if applicable?- -•r
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stonnwater Drainage R. ft.
Experimental Technology OSuhsidence Control ft. ft.
..;
Geothermal(Closed Loop) Tracer, 20:DRII liING.LOG:(athich additto6al sheets iL:iiecessary) t n.4a 5 ,r, ._.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM ft. TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
ft.
4.Date Well(s)Completed: `I- I t,' ' Well ID# 33-Do Li ft. ft. ; ' n r,: „', .
5a.Well Location: f 5 ft, 9.6 0 ft• r. -S7 o c_- 3 It L '1�if V' M a
U'1-tri e� - ft. ft. MAY 0 C 2024
Facility/Owner Name Facility IDK(if applicable) fL ft.
1 So kit__ 3o bS ;7$O6 ft. ft. ih>•.Vhrti..'.,.: i::,, ' ..
Physical Address,City,and Zip ft. ft.
B4 ,21:REASARKS t`F _ fl . . . s ` '$ .- III 3_`C a:NAZI
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: 1.
3S. gi3)a N _ -7G. 9Li 5.S W t-/,I2_a(--1
6.Is(are)the well(s)ePermanent or QTemporary signature o Certil d Well Contractor Date
Br signin this f rut.I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or Eil<o with 15A NCAC 02C.0100 or 1 SA 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 cop'of this record has been provided to the well owner.
repair tender=21 remarks section or an 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: 6 D (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 a200'and 2 g100') 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
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11.Borehole diameter: eQi (in.) 24b.For Injection Wells: 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: t\O a� construction to the following: 1 11
(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
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13a.Yield(gpm) 0.S00 Method of test: 40 imp 24c.For Water Supply& Injection Wells: In addition to sending the form to
'J the address(es) above- also subunit one copy of this form within 30 days of
13b.Disinfection type: H'I1i Amount: S It)$, completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016