GW1--04572_Well Construction - GW1_20240731

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: •
1.Well Contractor Information:
et 50 h Qo6 I PJ r, 14,WWATIrsIl:ZfiNE4 ;r s ,..,::; ,
FROM TO 7-DESCRIPTION
Well Contractor Name
ft. �a0 ft. . a j1 m
Y ft. R. .J{_,�
NC Well Contractor Certification Number 15 OUTER CASING(for:tttulti cased'wells).OR LINER(ff ap 'liable)ra J ®y��e i Vell i Ptovxf �A' FROM TO - DIAMETER THICKNESS MATERIAL
Company Name d ft. i b s ft. _ IQ VI in. $d D 411,1 n i
a y 1 �y [ :`16:DN1�1&RCASING OR TUBING(geothermal'closed loop)r
2.Well Construction Permit#: &. —0 0 1 3 i1 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: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ittkesidential Water Supply(single) fL ft in.
❑industrial/Commercial ❑Residential Water Supply(shared) ` 18.`GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MA EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. aA ft. 11 bibtuft.. ra v .
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft, ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SANDIdIt 4VELPACK.(if appiicab --
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft- ft'
❑Experimental Technology ❑Subsidence Control ft• ft.
❑Geothermal(Closed Loop) OTracer 2d:13RIGLING 1.O4:(attach'additional Sheets if necessary} "
FROM TO DESCRIPTION(color,hardness,soilirock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) 0�❑Other(explain under#21 Remarks) ft. (50 ft. ���Y 1r
4.Date Well(s)Completed: i d(i-. f Well ID# I O f 51 [So It• 710 t q rc 4i t-ty... roc,is
ft. ft LJ
5a.Well Location:] (,Te Creek _ y ,
1, 5 ft. ft. ......,'.....
Facility/Ownerame Facility ID#(if applicable) ft' ft- :I f!, 3 -b ?G 2 4
11-.'gyp O W G+. 1 Mr)�I Gs1LX ft. ft. -.
ft. ft. if .. y, Y t�
Physical A City,and Zip . s "'
( 35°5 3g 21 RI MARIKs _ . r , ,.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W sQiI914 dte..P./ l''' 7- aci
of Certified Well Contractor Date
6.Is(are)the well(s): ermanent or ❑Temporary
Sign
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or To 15A NCAC 02C.0100 or 15A NCAC 02C.0200 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#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 construction info
construction,only 1 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: ��0 (ft.) Submit this GW-I within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(gi200'and 2@:}1003
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: v (ft•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" t
4 /� (in.) 24b.For Inlection Wells: Copy to DWR,Underground Injection Control(TUC)
11.Borehole diameter: Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Q(r rd-ta ry 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) / county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
6 Ian Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:1_1 13b.Disinfection type: ti+-h Amount: 2- II)•
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018