GW1--03337_Well Construction - GW1_20240603

t yy,ylWELL CONSTRUCTION RECORD (GW 1)
For Internal Use Only:
1.Well Contractor Information:
) amisC� (mot
�S C‘r 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
L}a93_ o ft. a,() ft. _�1 I��
NC Well Contractor Certification Number a+�t, 2�. ft. Hot n 6��
c�., 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
)'C e_t��-3 ) 1 fC, FROM l
TO I DIAMETER THICKNESS MATERIAL
Company Name ft. ft.
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: C) 2 2)- ()Ur)SS-- FROM TO
List all applicable well construction permits(i.e. UIC,County,State,Variance,etc.) (7 (�ft. DIAMETER THICKNESS MATERIAL ft. (o• ZS to 52 I TVe
ix
3.Well Use(check well use): ft it in.
Water Supply Well: 17.SCREEN
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
QMuni al/Public ft. n. in.
Geothermal(Heating/Cooling Supply) DRfsidential Water Supply(single)
Industrial/Commercialft. n• in.
Residential Water Supply(shared) ,
Irrigation18.GROUT
FROM TO .1IA.TERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring Recovery (] ft. p it. ' �� rt\ P6�)?-
Injection Well: n. tt �C
Aquifer Recharge Groundwater Remediation ft. ft.
Aquifer Storage and Recovery Ehalinity Barrier 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft. -
Experimental Technology OSubsidence Control
ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) fOtther(explain under#21 Remarks) FROM TO :DESCRIPTION(color,hardness,soivmek type,grain size.etc.)
fL 10 tl
O C-(2 y t/ _ ( 11_Ycifh 4.Date Well(s)Completed: S-c3D-;Li Well TM 9 p n. /1 Os- ft-
`l 611r11n
5a.Well Location: ft. ft.
20 Bt-l:1,ees) L LC, ft. ft.
Facility/Owner Name Facility IDk(if applicable) ft. ft. - -`
"1 a,ri e r r s ci qp RA_ t )(o vr.e. A'\1.f t N�. 2 8181 ft. ft. G
� J1J1I �GZ4
Physical Address,Cityanr Zip ft. ft.
1Jt..l�C C 1 11 3 1C, 1OS 1 g DOGl7� 21.REMARKS
County Parcel Identification No.(PIN)
fib.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is suficient) ///
22.C Mention:/ J_
3S 0 i-13 1 .1 7.4 G° i 3l'N k2°A(-1) 30. Z 2S8 tl w -
_ z�
6.Is(are)the well(s) Permanent or Temporary Si twe of Certified Well Contractor Al Date
Uate
By signing this form,I hereby certify that the well(s)was(were)constnicted in accordance
7.Is this a repair to an existing well: DYes or o with 1 5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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:
3UBmITTAL INSTRUCTIONS
9.Total well depth below land surface: 140
For multiple wells list all depths ifdierent(exam le-3 (ft') ons4a. For All Wells: Submit this form within 30 days of completion of well
p (¢�200'and 2@100�
construction to the following:
10.Static water level below top of casing: )(D D (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing.use"+••
a 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.)
,pp 24b. For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: V�DtQ1e.�{ above, also submit one copy of this form within 30 days of completion of well
(i.e_auger,rotary,cable,direct push,etc.) J construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) /0 Method of test: Qct,1. (c-x-t ;�0 4c.For Water Suaa►v& Iniection Wells: In addition to sending the form to
`J the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: C,h IOt-t1^-e_ Amount: 4 ci- 4),I completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental(h,pt:r.._n:.,:..:,._,.c.,._.__.,