GW1--05281_Well Construction - GW1_20240906

1.We Contractor Information: 1,3Pi ize
y
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Well ContracttorName FROM TO DESCRII'rICN
' t Y ft- ft. -----
NC Wel ntractor Certification.Numb er
(' IS OUTER:CASING(for multi:caietl welLalOR'LINER(if applicable) .:."-3: r2"':...
/ `i�// I'/ / �i FROM TO DIAMETER _THICKNESS I dATERIAL
,// (((ill f rrrfff ., 7 II/_ /
Company Name fr. J ft. ` in. t� /
N/
.16.1 INER CASING OR.TUBING eiithermnl cidsed4aiii
2.Well Construction Permit#: ` 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. ir.
17.SCREEN. .,,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public • 0 ft- ft in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft ft in.
Industrial/Commercial (Residential Water Supply(shared) •I8 GROUT,. ..
gation FROM TO MATERIAL _ EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft fr.
Monitoring Recovery ft fc `,fj/r��/),7 µV
Injection Well: �KY�✓� v
ft ft.A uifer Rechar a �GroundwaterRemedia tion 19 SANDIGRAVELPACK(ifapplicable'I' ••...:.: ....._...-.:
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL _ E ,.MPLACEMENT METHOD
Aquifer Test f StormwaterDrainage ft. fr.
Experimental Technology IDSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.'DRILLINGLOG attueb"additioriali[xeti'if13eeeiia
Geothermal(Heating/Cooling Return) n Other(explain under#21 Remarks) FROM To DESCRIPTION cloter�eutoeu,wmmcktype,gratnmaete.I
/, fa ft. * ft
`'�g,r. `r[i,
4.Date Well(s)Completed: - '?�/ Well ID# / ,�,.2 fa /7.2 it. v�i/
5a. llLocallow ,S ft- 2/i t- / rj�r/lr2r. )'l1) 1 b ' (7.._ -.
77 l(//I.) I)el/7A �//t .%pl , S ft. ft. 1. %``.i'`. 1- •
Facility/Owner Name F etlityID11(ifapplicable) ft. ft. . -
451 41 Q}�/.5re i�d. /f /,47 / ft. ft. E. a b 2024
Physical Address,City,and Zip ft. ft. tnifgf.ti.Vt'1 ro,r-4#C.:�"J U.4
r/,1)1 1�/1'/ • •21:RE�MARKS .'s /: ,`. ;t ../n ...k.,.. j. ,
County Parcel Identification No,(PIN) 1.1171 r L- ���[/t l U/c t' -
J� / y�� Q
5b.Latitude and longitude Indegrees/minutes/seconds or decimal degrees: 1) L4' �f,�/ MvTi(^Lf/l.ly5 I,l• .A 'T.i
(if well field,one lat/long is sufficient)
) `?! l cj? N ;Jl, G3,25? w / CYiti hliq'f/!�/// ' 7t; 7
6.Is(ace)the weII(s) rmanent or Temporary Signatureof,CertifiedWellCo❑factor Date
By signing this form.I hereby cerffjy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: !._!Yes or TtNo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well 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 well 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 Ia 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
fL(/ )
9.Total well depth below land surface: ` G' 24a.For All Wells: Submit this :[arm within 30 days of completion of well
For multiple wells list all depths Ifd fferent(example-3@100'and 2®I00•) construction to the following:
10.Static water level below top of casing: (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: 7- './ ? (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
/fit � �T/� above;also submit one copy of this form within 30 days of completion of well
(ie.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: // 1 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) .9 Method oftestl:01 /' //IT • 24c.For Water Supply&Infection Wells: In addition to sending the form to
-/ ! /I 7 .. the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: t , Amount: !4 i/ `2 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