GW1--04013_Well Construction - GW1_20240708

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.,WW II Co tr. for Info i/on�:� /
t/t �i ;) ` 1/1 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
P 6 -F. CO ft.
{�( 1/ ��'ft. ft. .
NC jT5V
tor C rtificati Numbe�1 /91/1 ,i; .. ! f 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
, i d7'-// / J / � / //�/ FROM ft. TO ft.
DIAMETER in. THICKNESS MATERIAL
Company Nai r
1�� 1 !� ✓ //
/ 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well CO:. ruction Permit#:S 1A/p�4/---0f1 l 0`'O FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc.) n ft. /,,/ ft. / to t4/5— gAL Y
3.Well Use(check well use): ft. R. in.
Water Supply Well: I 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL,
Agricultural IMunicipal/Public ft. ft• in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single)
Industrial/Commercial
ft. ft. in.
Residential Water Supply(shared) 18 GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water limply Well: ft. LL rt. h � / f/7 3r, 1
Monitoring
Injection Well:
Recovery ft. ft.
ft. ft. ,
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(If applicable)
Aquifer Storage and Recovery JSaiinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test �Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION(color,hardnessvee ,soil/rock type,trait site,etc.)
g/ g Other(explain under#Z 1 Remarks) A
4.Date Well(s)Completed:rjJ'{g)Z.f�� Well ID# / 70 0 7/ I.
n. n. BA ru.�4, ,,
5a.Well Location: 4/�_ ft. f ft. ,-' ��/-2 /-rLr 'c
. X T /AA/A/i-/z /7O 7oO/s. 5�q��''' 7 ft. Wf2 n. � /A Rod k
94 ft. ill R. ,HIV i Gk
Facility/Owner Tjlamc Facility ID# if applicable) t,:4_ �� �G
27C} -rl ,Gx s G/<«. Rl), MA),ems/y" ft. ft. Fi:: ,f iv EL✓
ft. n. i>~. J
Physical Addrc City,fand Zip JUL8 7 7 f
44C Dakiwa 21.REMARKS L 0 ZOZ4
County Parcel Identification No.(PIN)
t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ' i S
(if well field,one lat/long is sufficient C'G 22.Cent''cation:
-Z.a.5-0.3 7 .06-4 N 1 U t,1 I ! 7 /�J W �� tf/7
6.Is(are)the Ivell(s) rmanent or Temporary Signature of Ce ed Well Contractor Date
By signing this form,1 hereby cerrih'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E3Yes or No with 1SA NCAC 02C.0/00 or 1SA NCAC 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 owl!caner.
repair under#1/remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Gcoprobe/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 WW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: /V SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 70 6 (ft) 24a. For All Wells: ,Submit this form within 30 days of completion of well
For multiple.cells list all depths i/di/Terent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: /0 a (ft.) Division of Water Resources,Information Processing Unit,
!f linter ley,.is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617 k
'
11.Borehole diameter: 6 (in.) r
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: 41 k R atia.ey construction to the following:
(i.e.auger,rotaryi cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATEll SUPPLYY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) c' J Method of test:Aei Q,L.1 1—T 24c. For Water Supply&Injection Wells: In addition to sending the form to
ff�' ` the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:CAL)1- A) C. Amount: 2, RJ completion of well co struction to the county health department of the rounty
1 where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016