GW1--05075_Well Construction - GW1_20240827

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
3---e,i1 ,---e—. R(' I4-s- C v ;-14;WAiTERZONFS
•
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
31. $ ft. ft.
NC Well Contractor Certification Number =. OLgIRRCASING 4for aed weisi OR LINER le
... /'} '--t FROM TO DIAMETER THICKNESS MATERIAL
I `J /t`,}4.,/•,D-'� (/it 1(. ft, ft. in.
Company Name 1"b itai}1tER'CAS1i(1G OR TUBING(Renthermal closed loop) i
FROM TO DLO/TETER THICKNESS MATERIAL.
2.Well Consti ur.tion Permit#: ft is j�j (/�
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.)-
— ft. ft. in.
3.Well Use(check well use): .
s 17-SCREENi
Water Supply Well: FROM ' TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricui uml oMunicipal/Public ? ft. I t,`Z ft- 2- '4 0)0 D / v c
Geothermal(Heating/Cooling Supply) DIResidential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidennal Water Supply(shared) ;.iB QttOfiT
Irrigation FROM _TO MATERIAL EMPLACEMENT METHOD&AMOUNT
N -Water Supply Well: Or S ft' `, `t. (z,:-'‘'-'r wives
Monitoring ORecovery ft- 5 ft- fie. 4:4-C C.;r/..,s/
Injection Well: ft. ft.
Aquifer Recharge DGroundvrater Remediation -:19 F NDl 'PACK(gapplicable)
Aquifer Storage and Recovery ()Salinity Barrier FROM TO MATERIAL EMPLACEMENT M EfhOD
Aquifer Test - . QStormwater Drainage 5 ft- ?�` ft- `/ ow Cv
Experimental Technology oSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer
a2&DRE ENNGIOG;(attadtadditionalsheetaB'atecesvary)
FROM TO , DESCRIPTION(color.4ardnm,soil/rock type,grain site,ete.)
Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) ft lr `"o�JSo` J
1
j zy pk - 2. fc ft.4. to Well(s)Completed: Well ID# 2 d^ � �r,,,,`'j
a7,2 ft. 6(2- ft. `.'NT,r.✓,,, C/��
51_Well Location:
Wilt/ r/( �1.4 j �(� ft ft
Facility/Owner Name Facility ID#(if applicable) ft' •__ ft. -- •
n 2,� ft. ft
(�10 V F/11i'no`ti RI
i�ei-C,, 1�1� 27`1 _ .
ft. ft.
Physical Address,City,and Zip
LF PIARKSi" i'OW -. ----... 'Jr
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.Certificatio : -
3e.1y4 i N brb, (0 5—L3N `y „, --' ----- 7, 2-`1
of C a''Veil Contractor Date
6.Is(are)the well(s) Permanent or flTemporary
Ry signing this for,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an erisaing well: QYes or 111"o with 15A NCAC 0.;.0100 or ISA D/CAC 02C.0200 Well Construction Standards ant(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:
You may use l'ile back 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
driii .. ` SUBMITTA':,ENSTRUCTIONS
S.Total vill depth below land surface: —1 2 (D-) 24s. For Al Wells: Submit this form within 30 days of completion of well
For piglitple wells list all depths ifdifferent(example-3@200"and 1 a@100') construction r the following:
10.Static water level below top of casing: (ft) Di ision of Water i .sources,Info-raation Processing Unit,
If water level is above casing use"+',/ 1617 Mail Set:'ice Center,Raleigh,NC 27699-1617
11.Borehole diameter (In.) 24b.For Il ection Wells: I- addition to sending the form to the address in 24a
/ above,also ,ubmit one copy cf this form within 30 days of completion of well
12.Well construction method: t ft"Lie/ I d 7---7 construction :i the following
(ie.auger,rotary,cable,direct push,etc.)
Divisic 1/'f Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail firer'nc a Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 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 completion of well construcion 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