GW1--03209_Well Construction - GW1_20240524

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only. MEET
1.Well Contractor Information:
Well Contractor Name FROM TO DESCRIPTION
��,� 3, - -Ai 5 \b C' ft. (., --.1 , -4-- cD S �--,
n. n.
NB ._4C Well Contractor Certification Number 1y^1��'
,.SJNNN 4 , L l v` \1 1C,, r\\ C FROM TO/ D aR THICKNESS MATERIAL
Company Name 1 h Lift. ( 9 tt (4 in. S 3.‘ Y C_- •
2.Well Construction Permit#: 1 c) 3. 0 O 3,V FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(ie.UIC,County,State,Variance,etc.) ft R in
3.Well Use(check well use): ft ft. i11
Water Supply Well: FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
Agricultural DMunicipsl/Public ft. rt. Is.
Geothermal(H 8/Coolmg Supply) EaRtitiential Water Supply(single) ft. ft. in
Ind usiriavcommerr ial ()Residential Water Supply(shared)
irrigation FROM TO MATERIAL. METHOD!AMOUNT
Non-Water Supply Well: 0 . a, L1l c tQ k 6 s (off S e i b
°Monitoring Recovery ft. ft. G t r
Injection well: - —
■A iu1fer Recharge ifcL:•r".�'sx s�: ()Groundwater Rarnediation ft.
s Aquifer Storage and Recovery t7'!'' ['Salinity Barrier
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStamtwater Drainage ft ft
Experimental Technology Dsubsideoce Control R. ft.
Geothermal(Closed Loop) OTracer
Geothermal(Heating/Cooling Return ['Other(explain under#21 Remarks) FROM 7p DORSR noN Woe,Yardman,sae/reek type,pats die,ek)
4.Date well(■)Completed: i 0\i o a. Well ID# S 1 ft t iS ft' C'o-.r+ ;`�-Q.--
5a.Well Location: \C S s 1 6-0 tt l s-€. I.CL !' Z Q c
_A vk A'-.,,\ &1\ -(-.\ 1 ,U13 it'. Itirk- &--C...,-,-..-lei-3/4-..-e
Facility/Owner Name Facility IDS(if applcabb) B'
Ck `c- n cc k` �Yk . �r c e r� r f. ft.
Physical Address,City,and Zip,\ t T, 4- 6 ft. ft. ------.
6wr Co v.„-be $bolo` l 603Tow°
Canty Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or dedmi degrees:
(if well field,one lat/bng is sufficient) 22. tion:
6.Is(are)the well(s)0ermanent or oTemporary Sig ue Ce;1ll Contractor Dare
By signing this form,I hereby oar*that the well(s)Wag(were)constructed in accordance
7.1s this a repair to an existing well: Dyes or DNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Sian her&and that a
'tidy is a repair fill oat brown well cansnvcrion brjonwation and explain the name of the ropy of this record has been provided to the well owner.
repair under 1121 remarks section or on the back of this forma.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells ha ' the same You may use the back of this page to provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMB of wells // on details. You may also attach additional pages if necessary.
drilled: , /
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) 24a. For AB Wes: Submit this form within 30 days of completion of well
For mnu/tipit welts liet all depths#'different(example-3®200'and 2®1001
construction to the following:
10.Static water level below top of casing: (0 L (ft.) Division of Water Resources,
if water level is above oaring,we"+ Information NC ■ Unit,
(�� lilt Min Service Center,Raleigh, 27699-1617
11.Borehole diameter: (L.-) (in.) 24b.For Infection 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:
construction to the following:
(ie.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: n 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(spas) 0 Method of test 1<< 24c.For Water Snooty&Infection 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: X i ti Amount 1 lL, e completion of well construction to the county health department of the county
where cananvcted.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016