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
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NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(If a Me)
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n. TO
n. DIAMETER
in. THICKNESS MATERIAL
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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
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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