GW1--04477_Well Construction - GW1_20240730

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WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
1.Well Contractor Information:
'& ter4-i ,'.(/�el6 14.WATER ZONES
Well mist-tor Name FROM TO DESCRIPTION
� a - A A70f. / ioft• S6,-,
NC Well Contractor Certification Number l C C'tt• (!% ��/�
/�/f/J lnl� L CF 15.OUTER CASING(for meld-cased wells)OR LINER(if a )
�r '/S Wes.I a/id I v'�C�t acy U-C FROM TO DIAMETER THICKNESS MATERIAL
ft. 6-Co. .:. Name / f S ft. G r 2 in. 5 Dg al "pre
2.Well Construction Permit#: I C�L/L/O /' 16.INNER CASING OR TUBING(geothermal elesad400p)
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.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
0Agricultural DM icipaVPublic ft, ft, in.
QGeothermal(Heating/Cooling Supply) Mfiesidential Water Supply(single) R. ft. in.
0Industrial/Commercial ()Residential Water Supply(shared) 1&GROUT
',Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. 1
['Monitoring ()Recovery ft. ft. R �i�� i r .�.&t-�C�
Injection Well:
ft. ft.
Aquifer Recharge DGmundwater Remediation3
19.SAND/GRAVEL PACK(If applicable)
Aquifer Storage and Recovery Salinity Barrier 0 FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft. ft.
3Experimental Technology thermal
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 TOc •
DESCRIPTION(ceder,hardness.toiYrodc type grain size,etc.)
, '/ �°"49�
4.Date Well(s)Completed: r' (off 7 Well ID# 0 ft. So ft. AY Q/ C%t P
5a.Well Location: .5 ft' 6 j ft' �ii•qr #1`"-'L
(ic&77:XC/iI,Y7 )0. (G . G et ft. d cS ft- c-t.. 4 -/e-C
Facility/Owner Name Facility_ci ID#(if applicable) ft. ft.13 g De �i7Q V tic p)9/1, ft. ft. ..
.�`�. .
Physical Address,City,and Zip G Qt/ It. ft.
` ` -,
6-, 5 n� 3 S C O J 9-r r 6 21.REMARKS Lu 3 0 .j o i+
County Parcel Identification No.(PIN)
Ire:.::,'...:- _ >
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: /_ D.`:c. St,,-;',(if well field,one 1at/long is sufficient) 22.CertifcatIon: crr�� (j a - A
3 S°aia 3 ‘o N (/ o /3o W -4c. "a /17 ? --� :r y
6.Is(are)the well(s) Permanent or ()Temporary ofCertified Well Contractor Date
By signing this form,I hereby certify tkat the well(s)sus(were)constructed in accordance
7.Is this a repair to an existing well: Q Yes or No• with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill our 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 I 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: c c (ft.) 24a. For MI Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(200'and 2Q100') construction to the following:
10.Stade water level below top of casing: ?U (ft.) Division of Water Resources,Information Processing Unit,
If water level Ls above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
]
11.Borehole diameter: L4
t1 (lit.) 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: 0...u� 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 ... y 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) is Method of test: C'(Q�TL[_ c.f�" 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`t Amount: d 0/6 completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016