GW1--03120_Well Construction - GW1_20240522

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
S-----1141 n /e �P.tZe g_ 14.WATER ZONES
Well Contractor Name
// FROM TO DESCRIPTION
185 4 ,ysft. ,y‘ ft.
670 ft. 6?511•
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ap ble)
j w S rLy WO
I I D li t r I I til 11 c FROM TO DIAMETER THICKNESS MATERIAL
Company Name l e . ft' Sr' ft- 6 'Kr is S/9tQ Z• PVC.-
' DO I 353 ri 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) fL f4 in.
3.Well Use(check well use): ft' ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural DM cipal/Public 0 it. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) rt. ft in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: U R• 2-4, f• I`k,474e..,'fwe_ 40..r-
°Monitoring 0Recovery ft. ft.
Injection Well: ft. R.
Aquifer Recharge OGroundwater Remediation -
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage
ft. ft.
Experimental Technology 0 Subsidence Control R. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size.etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) 0 ft. w ft. G l
,44
4.Date Well(s)Completed: 2'/f/2-41 Well ID# 24., f. yd H. 1„-,an,T40 ,,,,P 6-/ wn Rodi,-
5a.Well Location: it, ft. v e, 6 0-,�
G Th ft. _ft. ,
7�"'y/ �o �3s G i
Facility/ r N e Facility ID# if licable) 1 7s Wit• .7O/ft. Gi,G
ft.
l 8,2, I 7 Ko ka ll I Ln. A/C ft.Physical Address,C ,and Zip .2-S'a7� ft. ft.
MtC
le„ uc 21.REMARKS 2, /f l7'1
County 1 J Parcel Identification No.(PIN)
7
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 7 iJ3
(if well field,one lat/long is sufficient) 22.Ce 0
N W
Ar (/ . Z _f t�0
6.Is(are)the well(s) ermanent or ()Temporary Si:.,: of Certified Wel ontractor Date
By signing this form,1 hereby certifi,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or ‘ with ISA NCAC 02C.0100 or ISA 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: 70 V (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@200'and 2®100') construction to the following:
i
10.Static water level below top of casing: 3 b (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: <j - (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
f /'�v rot."' above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: /fi tr 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 Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) t Z- Method of test /Cpw 24c.For Water Supply& Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13h.Disinfection type: It / /'1" Amount: 1 YtiZ� completion of well construction to the county health department of the county
where constructed.
Form G\1-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016