GW1--03684_Well Construction - GW1_20240618

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: /`-/)
)(-r ,Sio- " (( L e-l/C.� 14.WATER ZONES
Welldbntractor Name FROM TO DESCRIPTION
(is a - Q /�'�. Y_2 sft. c;r�,
rt. n.
NC Well Contractor Certification Number
/��/%/�/1'.{ -yI �,//�/��,, _�% 1� /: / / 15.OUTER CASING(for multi-cased wells)OR LINER(if ap}plic?Ire__
able)
v r5 Well` lit/ 1l t�1 l !'mil L'�2l J� 4�4�. FROM rt. /56tt. DIAMETER. (n, 5 THICKNESS I Y IrC MATERIAL
Corn Name / > 9'C ` I1 l'�j
16.INNER CASING OR TUBING�eotdertnal closed-loop)
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: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural D icipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
IndustriaUCommercial 0Residential Water Supply(shared) 18.GROUT
irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: tL 3� ft. �`` ''
Monitoring DRccovery ft ft. bi(J J I of- I � i t)l
injection Well: ft. ft.
Aquifer Recharge QGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) D Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,sail/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under 021 Remarks)
o ft I.)C) ft. 0/1),-.4- y
4.Date Well(s)Completed:S-JI�y Well ID# /)S ft. /J G ft. 6 ,�-�J..�_-
5a.Well Location: 1ST ft. j� C ft. G r`4,f7��
r5' ./e Co/ siG?a J$ . ft. ft. ,',
Facility/Owner Name Facility ID#(if applicabl ft. ft. s`��' 1
7 5 (4(Il /C�i Ai if,,,s,47-4- Pf ft. ft. JUN '1 8 2024
ft. n'
Physical Address,City,and Zip
�- +..'rc�n'5 a.*rry �,dg t t11�
G. QG/ u� S 1� 02 G%?U S 21.REMARKS IriVA:CI/04
County D Parcel identification No.(PIN) _
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r� 4 l
cs.
(if well field,one lat/long is sufficient) 22.Certification: oC J . - 4
35 v/a /38V N i/ //lS}d W
6.Is(are)the well(s)iiYlPermanent or Temporary cur of Certified Well Contractor Date
7777""���C By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or No with iSA NCAC 02C.0100 or ISA/t'CAC 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 we!!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: y S SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / 5,
(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: 3 S (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: Ict I'' (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
C)�� above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: '?)CA:- 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) S Method of test: ^C)(-4 Li' It+ 24c. For Water Supply& Injection Wells: In addition to sending the form to
� I -1. --
�/� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type `<-�t t 1t Amount: .? LT'5 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