GW1--03849_Well Construction - GW1_20240628

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: RECEIVED
He 5T!'/ 1/, ,S5 Ut.Z.) MAY 06 2024 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name it. ft.
z?3 7 S' -- /7 NC DEQ/DWR ft. ft.
NC Well Contractor Certification Number Central Office 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
I
/t6/ - FROM TO DIAMETER THICKNESS MATERIAL
�t! rr5 s��= �Q /___ A ,{, ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal clased-ioop)
2.Well Construction Permit#: W/6.Cr 69D A V 7 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State,Variance,etc.) () ft. ?Oh/ft. / in. �4 // /�
/ ( O//,Gf'9,kiIC
3.Well Use(check well use): ft' ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipaVPublic ��ft. ft. in.
Geothermal(Heating/Cooling Supply) 0Residential Water Supply(single) ft. ft. in.
Industrial/Commercial 0Residential Water Supply(shared) t8.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: J di ft. 0 ft. the / rre . /n r';f �1, rc'_
°Monitoring 0Recovery ft. ft. (� ,n.\ I
e•?4GA«L�/ "Iv.1-176r!
Injection Well: ft. ft.
gAquifer Recharge 0Groundwater Remediation S4/1�%
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage >N ft. ft.
BExp 'mental Technology 0 Subsidence Control ft. ft.
eothermal(Closed Loop) 0Tracer 20.DRILLING LOG(attach additional sheets if necessary)Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTIONp (color,hardness soil/rock type,grain size,etc.)
``'' ft. ft. S!i nil �1��� S6,
4.Date Well(s)Completed: V 3°27i Well iD# S ft. S, A ft.Ci $ C 'e.-i4. fo.h `/.4,
5a.Well Location: >T ft ft.v . /)-O G,.o,`,e O/ FS,,I ,.-J:)
Ho 4 ar Cvu,d-/ li,p) S`-xTC,> at ft. 1 7o Scc1.' '/ A.- 6.4,
Facility/Owner Name Facility ID#(if applicable) /2 0 ft. trU ft. /
5i .5 8,A//t/ AO, i? a E',..1-) .2cri'n, 2.0 V ftft. -5t�J C ft. `)G.rG( �itr., t c /t/t_
. ft.
Physical Address,City,and Zip/ D/ e 6,-"Li.)I`/
'j 7� 21.REMARKS/ /t it ' t I
County / Parcel Identification No.WIN)) ry v 2- `-/SCN • t...._ %/ t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: JUN 1 $ 2024
(if well field,one lat/long is sufficient) 22.Certification:
9 div 545'/A8i/ I N -L 9` !_ / -5,Z-Cc a N 11164r it '!.,'J! jq�r/'
6.Is(are)the wells) rmanent or Temporary Signature of Certified Well Contractor Dale
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: 1:1Yes or Et< with ISA NCAC 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 ofthe copy of this record has been provided to the well owner.
repair under#21 remarks section or on the hack 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: s�
6/ 6 �t^> /// �( SUBMITTAL INSTRUCTIONS
!'I
9.Total well depth below land surface: Il Ye) l( (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: ' (ft.) Division of Water Resources,Information Processing Unit,
If nester level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: . .5 (in.) 24b.For Injection 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: 6// 4 p f-4„// 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) Method of test: 24c.For Water Supply& Injection 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: Amount: completion of well construction to the county health department of the county
u
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016