GW1--03461_Well Construction - GW1_20240611

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Co tractor Infor�mattion:
14.WATER-ZONES
Well Contractor Na FROM TO DESCRIPTIONTIy/)
• '.. `I�d ft VCS ft `b ql"-
`{��� ft. ft J
NC Well Contractor Certification Number 15::OUTER.CASING:(for inultitased wells):OR LINER('f ap licable)
Mor an Well &Pump) INC • FROM TO DIAMETER THICKNESS MATERIAL
— — I /''� - - a ft 4 ft s tea rn• sdr2i pvc -- -
-9 1
—_=_--_____ - 16L'VNER=C-ASIh'GOR-'1'TJBIIV^r(geaL...r...o.closed-laap)... •'- -----
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft ft in.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
QAgricultural fMunicipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) NResidential Water Supply(single) ft ft in.
qI Industrial/Commercial OResidential Water Supply(shared)
I6:'GROUT �.
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• bentonte poured
Monitoring QRecovery ft. ft
Injection Well:
ft. ft.
Aquifer Recharge Q Groundwater Remediation
19.SAND/GRAVEL PACK a cable
(�applicable) - "
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft ft
Experimental Technology El Subsidence Control ft. ft
Geothermal(Closed Loop) [ Tracer 20..DRILLING"LOG(attach additional sheets if necessary)!;.i- ::::.:'_. :: ": .. :.:j
FROM TO DESCRIPTION(caior,hardness,soi/rock type,grain stee,etc.)
Geothermal(Heating/Cooling Return)` ,[' Other(explain under#21 Remarks) 6 it 1� ft �Y�� 'IW,IR�►avr+`Y't{K.►
4.Date Well(s)CompletedEt�i I y't Well ID# `ems ft. 3�r, ft 6t r�k
5a`Well Locatite♦� f{{ '5S ft. -2„3`ft. 6v.x.
(60 i
V�i`n`- r '}•1}�a�'-��e ft G a aC 7ft.
Facility/Owner Name J l Facility ID#(if applicable) ft ft.
NL2B1 ft ft. — C�L �� �.
iota Address,City,and Zip
`� ft. ft. JUN 1 1 2024
21;REMARKS ` ::
County Parcel Identification No.(PIN) +$t 11,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
-. S.S. Lttfr—t Q3 N (�its.4,.4g.\ W . J 5 3p"
6.Is(are)the well(s)JPermanent or Temporary Signat Uertified Well Contractor Dat
By �1 is form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or 1)No wi• 5• 'CAC 02C.0100 or 15A 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: 2-0C) (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@100) construction to the following:
10.Static water level below top of casing: (\D (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: 6 1/8 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
rotary above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 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) \C Method of test: air 24c.For Water Supply&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: granulated chlorine Amount: if,:7j completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016