GW1--05313_Well Construction - GW1_20240906

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
?— \i b 14.WATER TONES
Well Contractor Name FR01! TO rt. DESCRIPTION,�t
ft.
al ;/,r j(�� ft. 3$ft. firm
NC Well Contractor Certification Number /"� { !'it"f
eitreatty' �) p ( ) 15..OUTER CASIO.NG;(for mul sed wells)OR LINER(If a Jble)
I� siii 1 o PUryp1 1�1 Tit (. , FROM
ft. T t!/ ft. (/t n(Li . THICKNESS MATER7 V iAL
Company Name fie` J '�i
1 l it t , / 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 'j--) �_.(/ '-1 t 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: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft, ft. in.
industrial/Commercial DResidential Water Supply(shared) iS.GROUT
irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. ?A. ft. l lxrrkt,�,t‘is
Monitoring DRecovery ft. ft. 1 y� i�
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation
Aquifer Storage and Recovery {{''''''�� Barrier 19.SAND/GRAVEL PACK(if applicable)
L_f Salinity FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QStonnwater Drainage ft. ft.
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) 0 Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardnca soil/rock typo grain size,etc.)
r ip,i, ft. j ft. (1 C , t
4.Date Well(s)Completed: 71 Z Z"[ Well ID# t ft 1'�Jvi�lyr ft C��/rylJ��'1 ;
Sa.Well Location: ft. ft. 3 c
lft, ft.Z.Qt in` � � ft. ft. SEP g g 24Facility/Owner Name Facility ID#(if applicable) O
.r,�' "/ i- pit, ]�( {
1)t? 11-0/.it 111- , -yiijs Ki.lic- ft. ft. Irto:r..ci�s,ct rl,-. •
!3 ems: /(i, t
jPhysical Address,City,and Zip ft. ft. QcJ�I r 3
i�y to,sI ii S1)n (' 03{3 21.REMARKS
County l(� r j Parcel IdentificationNo.(PiN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Ce ''cation:
35 , 3 SAP N — 8Z_• 3U3 W ,,
'tiU,I------ cl IZZ IZL1
6.Is(are)the well(s)Jo Permanent or OTemporary Signature of Certified Well Contractor Date'
Br signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ONo with 1SA NCAC 02C.0100 or I5A 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 cope 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: iSUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ( (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@2 0'and 204100') p
construction to the following:
t
10.Static water level below top of casing: 10 (ft.) Division of Water Resources,information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
La(
;� it
11.Borehole diameter: t,ll '-.{ (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: '(i above, also submit one copy of this form within 30 days of completion of well
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
IA
t.----
13a.Yield(gpm) L/ 1 Method of test: \ 24c.For Water Suoph'& iniection Wells: In addition to sending the form to
t', the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 11 i 17 Amount: (Jr! 1VJ1 ..- 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