GW1--05280_Well Construction - GW1_20240906

(—'------- •. I ova 11LL1,11LOL VJG VSLLy.
1.Well Contractor Information: e.,cl
-
bigri 5sheiJ 1 // 14.•wATER ZONES::-: '-: ,. .. .. .
Well ContractorName FROM TO DESCRIPTIIN J
t 3 t t !/ 1 ft. ft. L' C l/)�� L�� /
ft ft.
NC We I Contractor Certification Number
��] w J { s1SiO1lTER:CASING(focmulfi=casedivelLv OR LINER(if aplicable)'':i;;`.:;.:;;:":s;
/ // �,5 �� FROM TO DIAMETER _THICKNESS MATERIAL -
Company Name Al �)ft. /� ft
in 3. 'tl )/�
16.'1NNERCAS GOR.TUBING'(Roottieivaitliloied400p)'`:;. 3dah:.'. _./:;',:;.,'.::.' r:• "•:.:;;
2.Well Construction Permit P. 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 0MunicipallPublic 0 ft fr. in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft in. —
Industrial/Commercial D Residential Water Supply(shared) I8'GROUT. ._
'gation - FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT'
Non-Water Supply Well: „ a
</ ft ft T!�f re a/r I v`y Monitoring nRecovery fL ft. i► ! [ — / [ ,
Injection Well: / ) /,'/
ft. ft-
Aquifer Recharge ri Groundwater Remediation
Aquifer Storage and Recovery Q��Salini Barrier :19 SAND/GRAVEL PACK(if applicabie)'.'r .:'_ ;::::;;�;; �::;•i'.::=:;'::;;,:';='s:_.:_.::...
!� tY FROM TO MATERIAL _ EMPLACEMENT METHOD. _
Aquifer Test f StormwaterDrainage ft- ft.
Experimental Technology IDSubsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.'DRILLING LOG attiich•idditional sheets ifnecessa
Geothermal(Heating/Cooling Return) �Other(explainunder#21Remarks) FROM TO DESCRIPTIotreotar.hardness.snlignek type.graIoaimeicl
Zi ft. 7 ft �7 t.;kie/�
c- � .l
4.Date Well(s)Completed: 1 /( , i4 Well ID# ))c 7 iL ���• g it. Ay.,s C /,
5a. II Location: /)' yy� -
//yJ' /i j ft-
5,k- ft- l DTt r:: $Ju S.!
�TT1/)✓)7 t (//iM J 4/�pe' ' ft. ft- •�» a��
Faciity/OwerNama Facility ID!!(if applicable) ft- ft.
n
433/n =/)//5i i Rd 2//rc'J21/ / ; ft ft. SEP 0 6 2824
PhysifalAdddr/ess,Ciity,anddZZiip ft ` ft ) ,.rl it•r... ;-,ri tJtia
/
I/!' 2- I/1' '21:RRMARKC";:. _ :'._p.:`.:_...::.'_. .._. / "t• _
County ParcelIdentificationNo.(PIN) /1t✓ �' giv T;! lr
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certification:
3 iiy1� , 71' N JL)PPoiV W ,�� �, ,��� ` 7-/7- �#
��
6.Is(are)the well(s)f rmanent or Temporary Signor,aeofCcLa6edWellContractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.13 this a repair to an existing well: DYes oro with ISA NCAC 02C.0100 or ISA NCAC 02C.,0200 Welt Construction Standards and that a
If this is a repair.fill out known well construction information and explain the nature of the copy ofthis record has been provided to the t veil owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the 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,only 1 GW-1 is needed_ Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /;?L (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfd 9erent(example-3@200'and 2®100Y construction to the following:
10.Static water level below top of casing: 3 C (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing use"+/ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: '.) (in) 246.For Infection Wells: In addition to sending the form to the address in 24a
I fl rf/ 1 above,also submit one copy of this:Form within 30 days of completion of well
12.Well construction method: , /// v 717 /
construction to the following:
(ie.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) 5L� Method of test / / t % 24c.For Water Supply&Infection Wells: In addition to sending the form to
N
7 f/ ,/ i the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 21%- completion of Well construction 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