GW1--03761_Well Construction - GW1_20240621

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I Print Form
WELL CONSTRUCTION RECORD(GW-11 For internal Use Only
1.Well Contractor Information:j2(,�( / �/f J
il l f / /l tip' 14.WATER ZONES
70
Wcnr ^rrectorNamo FROM TO DESCRIPTION
qC'o/9 6f' ft f1.; 4reC ID//^4
ft.
NC Well Contractor Certification Number
IS.OUTER CASING(for multl earned.wells)OR LINER(If )
oAm an Drill, Inc TO D L °P IT -
Company Name 7 IL LIn. / ""/��`,
16.INNER CAa OR TUBING(elaithermal
2.Well Construction Permit#: p` Yo. IT31' FROM TO DIAMETER TICK SS MATERIAL
List all applicable well construction permits(i.e.U!C County,State,Variance,etc.) ft. R. in.
3.Well Use(check well use): ft. R. In.
—
Water Supply Well: 17,SCREEN
A CUItUral PROM TO DIAMETER SLOT SIZE THICKNESS ' MATERIAL
gri OMunicipal/Public R. ft in.
QGeothermal(Heating/Cooling Supply) j;; '..idential Water Supply(single) ft, R. in.
QIndustrial/Commercial a Residential Water Supply(shared) IS.CdtOUT
"Irrigation PROM To NJ TERLU, /,.,,� T METHOD a AMOUNT
Non-Water Supply Well: A ft. 2_ R, f �A!- ���`tL jle),/a( oite -
°Monitoring Recovery L� R. LO !!�� Au• f. /
Injection Well:
A uifer Recharge ft. ft. --
q B QGroundwater Remediation
Aquifer Storage and Recovery Salmi Barrier 19.SAND/GRAVEL PACK(If appllntbie)
['Salinity FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage ft. it
Experimental Technology Subsidence Control ti R _ —
Geothermal(Closed Loop) Tracer L.DRILLING LOG(attach additloaal sheets if n
ecess
ary)
Geothermal(Heating/Cooling Return?) f Other(explain under#21 Remarks) n'OA R. T 1( •ft. 1":531(rn)N teolor, dw hanbew,. ad,type,arala,ze'ar.l
4.Date Well(s)Completed: `�/113/ 2 /Well 1-fr.1-fr. f1t. fir//7 ,.
Sa.Well Location: R. 3,0 ft.
1 D
30 ". Itf f. 6/a,-1, 7`-e ,
Facility/Owner Name Facility 1Dk(if applicable) J R. f.
/" ace F//1'l Ad N'1 l•a)n,, 1 /l R. ft.
by y s,City,and Zip ft. ft,
-_ t-.k e if 41
l�rho.._ ; Il.REMARKS 1i4P1 9 1 2624
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutesiseconds or decimal degrees: Imo' ..i. :R UlEak
(if well field,one lat/long is sufficient) 22 eati0 'r' 'f
.3i. 21776 N 725, 7s'3/56 w
6.Is(are)the well(s))Permanent or QTemporsry Signature of Certified Wet C for Date
Br Signing this firm,I he cen j•that the we/l(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ()Yes or d9No with 15A NCAC 02C.0f00 or ISA NCAa7 02C.0200 Well Construction Standards and that a
If this is a repair,fill ma known well constnrctian informatio_i izu('explain the uahve of the copy of this record has been provided to'he well owner
repair under tl2/remarks section or an the back of this%arm.
23.Site diagram or additional well details:
8.For GeoprobelDPT 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 CW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also Mach additional pages if necessary.
drilled:
J j`- SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ) (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiJferent(example-3(200'and 2®1001
construction to the following:
S`
10.Static water level below top of casing: 0 (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: L' (In.) / 24b.For injection Wells: in addition to sending the form to the address in 24a
D
12.Well construction method: A(/ /1V Ilty'� hTis above,also submit one copy of this'fitful r within 30 days of completion of well
r 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) .I ) Method of test: I bd/1L 24e.For Water Sootily&Injection 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: /1 77/1/7d !%Amount: /6L,jf 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