GW1--05076_Well Construction - GW1_20240827

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
1.Well Contractor Information: r
1'/,Gry1 € ,/ (•v fp I :WATER MINES
FROM TO DESCRIPTION
Well Contractor Name 1 g, ft
j �- ' 7 ! / ft_ ft.
NC Well Contractor Certification Number =; :plhfMtt CASING+7oc tedwells}OR LINER(if app&cable)
FROM TO DIAMETER THICKNESS 11 MATERIAL
'S 1 b e e l'/r �l ,',t) s. =t. 1 in.
Company Name ';16:;$NER CASING OR TUBINGiti others atchneu-leop)
2.Well Construction Permit#: FROM TO DIAMETEI. THICKNESS MATERIAL
List all applicable Well construction permits(i.e.UIC,County,State.Variance,etc.) 0 ft. 1 ft- ‹1.) .n. �(d t�
ft ft. in.
3.Well Use(check wet use):
-S ::
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
jj Agricr viral DMunicipal/Public 7 ft. 4 L ft. '- in. ` O -) t_C Pk'
Ng Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ' ft. I in.
It Industrial/Commercial OResidenfial Water Supply(shared)
on FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Ni.`water Supply Well: 2,cft. 3 It. C'°,,,dv - r Co`,,,s,DA
kir Monitoring ORecovery ft / ft h( o (t4,,,' j p(°v/ter/
ft �Injection Well: ft
*Aquifer Recharge Groundwater Remediarion 19F . A °PACK(lfapplcable)
*Aquifer Storage and Recovery EtSalinity Barrier FROM TO MATERIAL i EMPLACEMEN:1 OD
I <pt./-e-
R.Aquifer Test . ' [�Stormwater Drainage � ft Ti_ ✓ fL !�
try,/(/
%Experimental Technology EtSubsidence Control ft. I ft.
I Geothermal(Closed Loop) OTracer 28. EHtT!",,IL G{ lsheeb9t'aeetssary)
I FROM ra DESCRIPTION(color,hardness,sail/rock type. , )
ft.
IN Geothermal eatin:Coo'.:Return) *Other(..lain under#21 Remarks . ft. _ref CO,_
. VO t f
-('2N Well ID# 0 Ltd- ' .�w f (/7 ft i .�
4. to Well(s)Completed: _ (/
•5 v ,t ct/� ft. 4,t!'�0;7 `_`7
Sa Well Location: I R
vkr ,C-IL L`r 1-4/ --
Facifi ID# ifapplicable) ft ft
Facility/Owner Name Facility ( _
j 'I% ft. ft.
1 6(9g v,(5 i A i ce✓ L �t?� 8� .� ,,� -, �•- — --
ft.
- Physical Address,City,and Zip 2 7 2024
ff ,. 3 1TA$KS' ,
6.4A.Z7 t.-..,-
Comy Parcel Identification No.. `IN) --
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: --
(if well field,one lar/lovg is sufficient) 22.Certffi tion:
3&, tl-4g61 N --74o .6 5-61,1 W 2- C-24-f
6.Is(are)the wells Permanent or ©ITemporary ignature of Certif d‘4,:11 Contractor Date
- By signing this fort,I h ieby certjy that the ri'i(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or 13" with 15A NCAC 02C.0'90 or I SA NCAC 02.C. 200 Well Construction Standards and.that a
copy of this record has„,yen provided to the wilt owner.
If this is a repair,fill out!mown well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form 23.Site diagram or Additional well details:
S.For Geoprobe/DPT or Closed-Loo Geothermal Wells having the same You may use the back of this page to^rovide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also aitac' additional pages if necessary.
drib'.. _ SUBMITTAL INSTRUCTIONS
► ' '1- -
,.Total voll depth below land surface: (ft) 24a. For All Wells: Submit this f:am within 30 days of completion of well
For1nJ1�pie wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resew es,Information Processing Unit,
If water level is above casing,use"+' 1617 Mail Service 0iter,Raleigh,NC 27699-1617
11.Borehole diameter: Y (in-) 24b.For Injection Wells: In addi m to sending the form to the address in 24a
/' id�I" above, also submit one copy of lb form within 30 days of completion of well
12.Well construction method: q v el construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources, 'nclerground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cater,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Inj_er_(1 Wells: In addition to sending the form to
the address(es) above, also subtr:•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 Resources Revised 2-22-2016

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