GW1--04474_Well Construction - GW1_20240730

11111111 Vtrtt
WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
1.Well Contractor Information:
.- Tr,�r 7,Slott ,.(LL'c/c 14.WATER ZONES
Well ntrector Name FROM TO DESCRIPTION
e4 a - A Y6e ft. W ft. lc G;-►,
ft. ft.
NC] Well Contractor`Certification Number/� [� //fit 15.OUTER CASING(for multi-cased wells)OR LINER(If ap cable)
, (pry ,r rs I f 1�I l /2/1 I`�,y„ ^ \I l n ` C FROM TO DIAMETER THICKNESS MATERIALJ
Compgp v Name I.lVJl1L 1 (a[ l: e A l i,V�.111 K.(� (�(r // R. 1 f(�/ R. G pr is 5 l�i i i I T F c
(,.,/� S 16.INNER CASING OR TUBING(geothermal closed-loop)
I
2.Well Construction Permit#: ! _3 S FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,eta) ft R. in.
3.Well Use(check well use): ft. ft in.
W r Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZL THICKNESS MATERIAL
Agricultural QMunicipal/Public ft, ft, in.
Geothermal(Heating/Cooling Supply) E3Residential Water Supply(single) ft, ft, in.
Industrial/Commercial DRtsidential Water Supply(shared) 1&GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 01 a ft.
19;n (. nP d le)
Monitoring 0Recovery ft. ft.
Injection Well:
ft fL
Aquifer Recharge QGroundwater Remediation
19.SAND/GRAVEL PACK(If applicable)
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®Stormwater Drainage ft. ft•
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,Yankton,sa�iYrodc type grain sire.elk.)
y 0 ft. !is IL &.'d cif/ ,r47,� d
4.Date Well(s)Completed:i�-2--GU-et /well ID# /�O ft.
15 f ft �j p*A.,"..72,-G_
5a.Well Location: '`O i S `t ft- YS ft- C-+ T
1�/�Phl/y-e, t/ ij/.7 , ,/ • ft. ft.
Facility/Owner N Facility ID#(if applicable) ft. ft. . - - -. . ..
t s CG/'//1 d /✓a//Gi A.c a fo,i ft. fr .,.. f
Physical Address,City,and Zip ft. ft. J IJ L 3 0 2U
6 S1-Gr) 4/61
21.REMARKS
County Parcel Identification No.(PIN) (It`.,: 6.i[ya.`,;s,r: ;IJrK
R"� ezn
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r�
(if well field,one lat/long is sufficient) 22.Certification: oC( 4 a - A
, idi9. 77 Ye N 81Y/v. dove W ?,,�r-1 , le/Zr 02-)2 -) t
6.Is(are)the wells) Permanent or Temporary ya""�""fCecti if�ed 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: DYes or IO with 15A 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 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 17 69 s (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiierent(example-3@j200•and 2(100') construction to the following:
10.Static water level below top of casing: /0 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
t
11.Borehole diameter: l9 '1 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
1 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: (1L,1-�J 1 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: L' , 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) L (J Method of test: i c Q+l t- f j 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: 3 C 6,x 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