GW1--04356_Well Construction - GW1_20240722

WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1.Well Contractor Information:
(/IA.! I-0 n- PG L��-r -14.'WATER'ZONES ,
Well Contractore U am FROM TO DESCRIPTION
f�.. ft. ft.
/ 4 //4P /- ft. ' ft.
NC W II Contractor
Certification Number 1/�1 e
� //{,� 15.'•OUTER CASWG(formulti cased wails)OR INER;(It ap Iicable)�/�-{� 7 �V e-1 r / uyrti am -� i2C' FRO/M ft. Tgq ft. DrAIZC In. THICKNESS MATERIAL
Company Nanre
/n� Y ;-'1b:iINNER-CABtNG bR=T BTNGi:(getRthecmal¢losed}loop)
2.Well Construction Permit#: h/ltirl1 eL- FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(1.e.UIC,County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft. ft. to.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS � MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) KtResidential Water Supply(single) ft. ft. In.
Industrial/Commercial DResidential Water Supply(shared) °;1g;;GROUT t e
^
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: (9 ft. �D ft. b n I t'/1.ite p D Gla -1, b Q .
Monitoring Recovery ft. ft. V
Injection Well: ft. ft.
Aquifer Recharge OGroundwater Remediation 19:SAND/GRAREI:PACK(if applicable)'`
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
f
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology [Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer '20.DRJLIilNG.LOG'(attach:additlonal aheeta-lt..necessary) . -
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO D CRIPT�ION(color,hardness,mlUrock type,grain size,etc.)
6 ft. 7 l� ft. i r l) l7 / G1Gt_y
4.Date Well(s)Completed: 7—/7;4 Well ID# q o ft. Jy'O JL'ft. j Yn�12l t�
II. it.5a.Well Location:
/� ft. ft.
C/ Oo 14Dh'tt�
Facility/Owner Name I' p Facility IDH(if applicable) ft. ft.
�I D 7d /7 Y rt— l lLd1, 1.0 ft. ft.
Physical /Address,City,and Zipft. ft.
its '
£3)krffe- 21 REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(if well field,,/one lat/longgis sufficient) / 22.Certification: //
(oL2,7 � N _g1' �3 g10 w Z-1 exfA/1 ,-f `�7
6.Is(are)the well(s)aPermanent or Temporary
Signature of Ce fled Wt 1 Cont for 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: JJYes or IllNo with ISA NCAC 02C.0100 or ISA 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 well owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: /' SUBMITTAL INSTRUCTIONS
J
9.Total well depth below land surface: d 5" (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths If different(example-3Q200'and
2(4)100) construction to the following:
10.Static water level below top of casing: `7 6 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
1
11.Borehole diameter: l /A (in.) 24b.For Infection 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: y9 O 1"iY y 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 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 Method of test: a-/ i 24c.For Water Supply&Infection Wells: In addition to sending the form to
rr the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:G/`IO r/it e, Amount: C i-&-Q-,__ completion of well construction to the county health department of the county
/ where constructed.
Form OW-I
North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22.2016