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HomeMy WebLinkAboutGW1--05312_Well Construction - GW1_20240906 WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 1.Well Contractor Information: lam)(\ �^s•�t kinS•0,-) 14.WATER ZONES FROM TO DESCRIPTION Well Contractor Name lC{ l cA J•-A- O n. S 4o n' He I l O' n. n. NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(If a Me) �`,. ^ p ` I C FROM n. TO n. DIAMETER in. THICKNESS MATERIAL fkA �1.� Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) 2.Well Construction Permit#: °( C- Z O Z 3 -0 .0 l 8 Z. FROM TO DIAMETER THICKNESS MATERIAL List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 n• St n• t!/ , 1 c in. 'Si)0 2 I vG 3.Well Use(check well use): n' ft. in. V I[ f Water Supply Well: 17.SCREEN FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL ❑Agricultural ❑M . ipal/Public n. it. in. ❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) n. n. in. ❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT ❑irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: it 02b n• ecFGtht ){„ Pouf-4 ❑Monitoring ❑Recovery n. n. Injection Well: n `P ❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) ❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD - ❑Aquifer Test ❑Stormwater Drainage rt. ft. ❑Experimental Technology ❑Subsidence Control It. ft. OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.) ❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) b it 50 n' c 1ct-,l over Insix wr d - 4.Date Well(s)Completed:8/2 12-14 Well ID# 6O ft- qaf n. C%ram, -1-e- 5a.Well Location: ft. 1 ft. Q n. n. Facility/Owner Name •3 Facility ID#(if applicable) ft' ft. 1. l 3 f f3s14 Ec1Ie- DR. tfertdr.rst�Ytt.il,lc? ft. n• S E P 0 6 2024 Physical Address,City,and Zip ft. ft. 21.REMARKS irul^e,itOG Hendea5an OGil-I SgLis 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.Certif 'on' II.ingi (. ° N22 . 29434 ° W - w g-18-2�( 6.Is(are)the well(s): ermaneot or ❑Temporary ignature of Certified Well Contractor Date By signing this form,I hereby certify that the wells)was(were)constructed in accordance 7.Is this a repair to an existing well: ❑Yes or ❑No with 15A NCAC 02C.0100 or 15A 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 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: 8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well 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: 90 5 (D•) 24a. For All Wells: Submit this form within 30 days of completion of well For multiple wells list all depths if different(example-3@200'and 2(100') construction to the following: 10.Static water level below top of casing: 5 1/ Q (ft.) Division of Water Resources,Information Processing Unit, If water level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617 11.Borehole diameter: L . 2 C (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a above, also submit one copy of this form within 30 days of completion of well 12.Well construction method: iA tli-cLiai construction to the following: (i.e.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 27699-1636 13a.Yield(gpm) y Method of test:del Cnvt Rom.rtat 24c.For Water SUDDIV& Injection Wells: In addition to sending the form to V the address(es) above, also submit one copy of this form within 30 days of 13b.Disinfection type: CLkIntn L�Y(- Amount: �` }s.lytf 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