GW1--03986_Well Construction - GW1_20240708

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WELL CONSTRUCTION RECO GW-1) .j) For Internal Use Only:
I.We Contractor3ei/i//
p matlon: �" �����
6' ) 14.WATER ZONES
Well Con r 18ame FROM TO DESCRIPTION
NC Well Contractor Certification Number l'l +
�///JJJ 111 }� 15.OUTER CASING(for multi-wed wells)OR LINER(if ap licable)
�/J �j, //�/� 5.' I �IIe FROM TO DIAMETER THICKNESS MATERIALA
Compan//yName'/// / ��1 oft / it in. , 3�a G�/ r
/�//J� �7 16.INNER CASIN OR TUBING(geothermal closed-loop)y
2.Well Construction Permit#:1 OA r i Z)Z2// FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.iIIC,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
DAgricultural �Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in.
13 Ininstrial/Commercial DResidential Water Supply(shared) 1L GROUT
II gallon FROM TO MATERIAL EMPLACEMENT METH D&AMOUNT
Non-Water Supply Well: Y TT
Monitoring Recovery ft. ft- �C'r, /l/7i
Injection Well: /
ft. ft.
Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK Of applicable)
Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage ft. ft
DExperimental Technology 0 Subsidence Control ft. ft.
DGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Coolin Return) ['Other(explain under#21 Remarks) FROM TO DESCRIP770N eobr,h ep ion/rock type,grain du etc)
] A / /0 '� %052 ft yr ,rivid a
4.Date Well(s)Completed: 4 Well ID# /9 ft• l97 B' 'oc h
5a.Well Location: /77 ft. /Dan ft. /,94,1Ie, (2/' J
G5
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- rx oldD1' ( ii
lFacility/Owner NamP1911eM
Facility ID#(if applicable)
Ilkg) )?ei MM r6r ile ft. ft 11 '1 J 8 2024
Physicgress,City,and Zip ft ft. t , _ ` i
v/r I 21.REMARKS Jo
(_)1'.i'.3 i -
County CCU/Cam/ Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
33. 3 e12 71-i N YD, g'Ai. 9 3 W .4 � %1 i),� - 6 -7- 1-,1
�
6.Is(are)the well(s)EWermanent or Temporary Signature of ified Well Contractor Date
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 o with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information nd 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: i SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: )P vU (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjerent(example-3@200'and 2(a3100') construction to the following:
10.Static water level below top of casing: .J0' (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: 17 t _CD _(in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: /' j j p 1.91 , ,1 above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
t FOR WATER SUPPLY WELLS ONLY: - _ 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test))' i i f> 24c.For Water Supply&Injection Wells: In addition to sending the form to
qq the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 9� bL 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