GW1--05074_Well Construction - GW1_20240827

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
J.li.1
~--`7 Ri i i '.114.1itkliTER2ONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
GI.I i /1
.2 4--":-.1 (T ft ft.
NC Well Contractor Certification Number r25dAihTERR'CASING flor:multi-eaa;ed wenal OR LINER(if no le)
/ FROM TO : DIAMETER THICKNESS lI MATERIAL
�c`5���/1✓ G ��� 1'�°^f J��i. ft. ft. in.
Company Name .;1b:;INNER'CASINGOR TUBING )
2.Well Consti ration Permit#: FROM TO DIAMETER TRIMNESS MATERIAL
List all applicable;.ell construction permits(i.e.UIC,County,State, Variance,etc.) . d ft. 7 ft. •Z I
in. (,TV(2 ;2-L/C,
ft, ft in-
3.Well Use(check well use): . .
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agrickatural OMunicipal/Public -7 ft• q'L ft. 1— in. 1 p3 v 0,0 pvZ:,
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) fb ft, in.
Industrial/Commercial Residential Water Supply(shared) i ,a ti ;
_ Irrigation FROM TO MATERIAL EMPLACEMENT/METHOD&AMOUNT
water Supply Well: O. 5ft' ,�,(
Monitoring QRecovey ft. C1,5 ft. °'VCR Z„ fro
Injection Well: ft. ft. I
Aquifer Recharge OGroundwater Remediation .'19...:SANDIG tVET;PACK(ifapplleabie)
Aquifer Storage and Recovery ()Salinity Barrier FROM TO MATERIAL EMPLACEMEN''METHOD
Aquifer Test . • QStormwater Drainage 9,5 ft C� ft. 50_/V'J (✓d✓'-,%/
Experimental Technology ()Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer
;.29 17 TGLOGfatlaeh dduinnaisheetsif.memo y)
FROM TO DESCRIPTION(color,t,nraae9s,soil/rock type,prim Sin,etc.)
Geothermal(Heating/Cooling Return) 010ther(explain under#21 Remarks) D i . i., ft. • 7.9 -=�J7
1 r Z— 2Y CO u—1 i! ft. ,e,' fe. �t•�—J\d
4.BUte Well(s)Completed: Well l)#
ft. al 2_ ft. 4,1`-.L1 p'I
Sa.Well Location: /
ft ft. •
Facility/Owner Name Facility ID#(if applicable) ft' ft. , .—
� � fL R
2 � CJe-r-�, ! 23
6 ob V`e�siv.1 / ft. ft. li 2 7 Z074
Physical Address,City,and Zip
G4-,,t-4,
County Parcel Identification No.(PIN)•
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. 'on:
36 ►Nt-t5-7 N —761 ��63� W - 5—
of Certified Well Contractor Date
6.Is(are)the we Permanent or °Temporary
y Sy signing this form,I hereby certify that the well(s)was(were)con,tructed in accordance
7.1s this a repair to an existing well: °Yes or NO with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Consrrucn'r.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 hcs been provided to the well owner.
repair under 421 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the hack 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?NSTRUCTIONS
II•
f.Total von depth below land surface: ` f �' (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For,mu'laple wells list all depths if different(example-3@200'and 2(100') constnr Lion to he following:
110.Static water level below top of casing: (ft.) Divisi n of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276'.9-1617
11.Borehole diameter: (111.) 24b.For Injection Wells: In addition to sending the fora to the address in 24a
` 'G� �t �� r above, also submit one copy of tits form within 30 days,•f completion of well
12.Well construction method: u V J construction tc the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection .'ontrol Program,
FOR WATER SUPPLY WELLS ONLY: 163E Mail Servie#C'nter,Raleigh,NC 276,99-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells: In addition t,sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount 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 Resour e: Revised 2-22-2016