GW1--03958_Well Construction - GW1_20240705

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well
/Contractor Infoormattiion: d�l P J I!7 0 J
6i 52er/7/" 14::WATEIt`7ANES
FROM TO DESCRIPTION
Well Contractor Name
- ft. ft. 3 pi»4) l 7.) 2- q phi a>
c.c. G i9 ft. ft. I3 9b
NC Well Contractor Certification NumberNN• -r— 13:OUTER:CASING{foG inultl cased:wel s)"OR LINER='(if ap Bcabie)
[/� L i J/ 5 1 /�_5 ; FROM TO DIAMETER THICIWESS� j MATERIAL
ny / J v L, ft. .? , ft. //� in. S 6 d! 1 J/. c._
Company Name [J
r,� J) < 1 G/�1 118
, `� 16.INN£R CASING_OR TUBING(geotherniaraused=loop)
2.Well Construction Permit#: (J / A 8 FROM TO DIAMETER THICKNESS MATER L
List all applicable well construction permits(i.e.UIC,County,State, ariance,etc.) ft. ft. in.
3.Well Use(check well use): ft' ft. in.
17.SCREEN.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICIOVFSS MATERIAL
Agricultural ii unicipal/Public 0 ft• ft. in.
Geotherm (Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/ ommercial DResidential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMEI''METHOD AMOUNT
Supply Well: 0ft' _ ��, ft. 13-zA/U%�i' :T^ f)f5 b/
Monitoring ID Recovery ft. ft. f)rAf)1 %p
Injection Well: fr
ft. ft.
Aquifer Recharge it Groundwater Remediation
19..SAND/GRAVEV,PACK'(If applicable)- ` ,
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer Tracer 20.DRILLING'TOG'(atacti.idditionel-Sheeiilf nbeissii')'
•Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION(color,ha eaa soil/rock type,grain size,etc.)
b� ]1! t v fl. J y n. vv /' 6 v/sv(e.4i
4.Date Well(s)Completed:.) t� Well W# v
r�'(�f' t�e ft
/'ir 1, CA' /�
'7/
Sa.Well Loca'on: Y Pa 4.3�• JA rI rc ,/74 q Ti
/l�1 eek ft. ft.
Facility/ ' net Name Facility ID#(if applicable) ft. ft. I `L`,e .! iE.L )
1 5 7/ /ley 5 C hiii fi• )/ I)7cp>,-.5J '/// , ft. ft. A 20z4
r
JUL
Physical Address,City,ap Zip tt ft. o
Cr I 1 21.1lEEFfARI4S'-
.l '� 11
,� �.` ,lydv x 44t , .-.e>.-v�Urx •.
County Parcel Identification No.(PIN) —" 171 C'CA;
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) .a 22. rtiftcation•
1573 77/N �e 9 ?Al byU W /� 3v
6.Is(are)the well(s) Permanent or Temporary
Signature of, itified elW lContractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed tp accordance
7.Is this a repair to an existing well: Yes or o with ISA NCAC 02C.01Gr7 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this Is a repair,fill out known well construction nformatlon and explain the nature of the copy of this record has betn provided to the well owner.
repair under#2/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: f I SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: 1 (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 t1200'and 2Q100') construction to the following:
10.Static water level below top of casing: 3 (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: V'V (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
/� j i'7 �r71 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
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13a.Yield(gpm) ,) •C Method of test 1! 1 1 f ) 24c. For Water Supply&Iniection Wells: In addition to sending Ole form to
T i/ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: /' Amount: /v vL. completion of well construction to the county health department of fhe county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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