GW1--04571_Well Construction - GW1_20240731

WELL LOINS I KUL I IUi' Kt l UKl) (lx VV-1) 1'or Internal use Unly:
1.Well Contractor Information:
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FROM TO DESCRIPTION
Well Contractor Name .-
NC Well Contractor t\Cie`rt/i�tttfi���cationNumber ` - 15.OUTER CASING.(formultl-casedHeihh).ORLII ER:(itaptliicable�i:�,'t6� ::i .1
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0 rTHtr KNFC$('q\ F�/pvy 1AV'` ft.
Q ft. in. I v is CI U h hCL/'
Company Name �] q/�� p/,, 16.[P1IdE1t•CA[SIN OR:TUBIN f eotheratsl cloned-loopy: .�
2.Well Construction Permit#: ��_ s ®®W FROM TO f 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: FROM REEK TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural Oly inicipal/Public ft. ft. in.
DC:: :;.::.^m_:Y�-r' ::c-o o.-rir ; O.o a._«..t ur,....-c...1.1;t::..:-` - i
Olndustrial/Commercial ❑Residential Water Supply(shared) :18 GROUT _
❑Irrigation ❑Wells>100,000 GPD FROM TO MATE EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. tO ft. bth i ' • r4vg /111111111111
OMonitoring ❑Recovery ft. ft.
Injection Well: -
ft ft.
❑Aquifer Recharge ❑Groundwater Remediation
119.SAi /GRAVEL.PACK Of applicable,
❑Aquifer Storage and Recovery OSalinity Barrier IR FROM TO MATERIAL I, EMPLACEMENT METHOD
r,''. --- I ft t ft. 4
❑Experimental Technology ❑Subsidence Control ft. ft. i
0 Geothermal(Closed Loop) OTracer '20.DRIf.LTNG LOG(attach idditionabheets if necessary)_
FROM TO DESCRIP710N(color,hardness,soil/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. a� ft- A
4.Date Well(s) �- �'Completed:� �� 3 Well1D# 1 b 5a. 70 ft. ( ® It. rain f e i(�
ft. �% ft t
5a.Well Location:pt_ t4 6}drs he . ft. ft. _ -
Facility/Owner Name Facility ID#(if applicable) ft. ft. I I 1 I Q t 1 G2 4
Q cso it. ft.
ar Pun Lk
ft. ft 'h
Physic Address,City,and Zip IA 3 LL 1 .�}
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County 6 S Parcel Identification No.(PIN)5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(if well field,one latilong is sufficient) 22.Certification: Q
N W ' . aaiA T/14p2?
6.Is(are)the well(s): tPermanent or :Temporary SignaCure of Certified Well Contractor Date
By signing this form,I hereby certify that;he well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o 114 NCAC 02C.0100 or ISA NCAC 02C.1200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under h21 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 construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I DO (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Pro"Cl)ssing Unit, 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: & (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(TUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well rnnctruction method: 1.4- c -alornr c.,.,s. ...r,t n o _r rknr I]a rs,-.met Re.turn WPM!C nny to the
(i.e.auger,rotary,cable,direct push,etc.) is (V rts4-al county environmental giealth department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
ID1 , Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) �® Method of test: w
13b.Disinfection type: lit rl Amount: i/Z. lb
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018