GW1--05320_Well Construction - GW1_20240906

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WELL CONSTRUCTION RECORD (GW-1) For internal Use Only: i-r
1.Well Contractor Information:� �
YUty is bret r/1. 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
0 fit. `' it. j qO0 VII
iZfe �J ft. ` ft. Ut4�l ���V
NC Well Contractor Certification Number
A��3S n ` ` 15.OUTER CASING(for multi-cased wells)OR LINER(If cable)
y-el IJy,�- tyli I/;Vi a i 1 P tN_ i t . .)1; Ire' FROM TO DIAMETER THICKNESS MATERIAL.
CCU.\\II r ,T V 1 r I1LY Y V T�/� 'flJl r`[l. �•�/ I ri(;,• fit. �0 ft. r ill, t in.
Company Name l �i( t--1• j
11 - � 16.INNER CASING OR TUBING(geothermal closed-loop)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): It. fit. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
0Geothetmal(Hcating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
industrial/Commercial Residential Water Supply(shared) 18.GROUT
I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: jr\ ft. TO ft. Fp tn}r,r,y,
Monitoring DRccovcry �J ft. ft. 1 11U Il.t,
injection Well: -
ft. ft.
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery SalinityBarrier 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater 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#2I Remarks) FRont TO DESCRIPTION(color,hardness,soilrock type,groin size,etc.)
y C' 0 tt. 1() ft.
4.Date Well(s)Completed:S 13 I2� Well ID# '70 ft. /1 nC' ft'
n
5a.Well Location: ft. !r�'� ft. CJ` (�
s
t.i)kilt 1/C..7!1(f - .�1 'l .
ft.� ft. �. �,I L.;.Y 1.-J -)
Facility/Owner Name Facility4a , ID#(if applicable)
Xis) ft. ft. S E N 0 6
W' RI Te tti 1c 1vciik V1t1!ie/I��jit Va1k'j [rl Is) ft. ft. Jf 2024
JCJ 1116v.i, E1� r,•r.�
Physical
a� Address,City,and Zip ft. ft. gnC�:,8
}any t:� i /r1 �i'� 21.REMARKS
County ,id e Y- 71'-uolylp
Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35sit N -0)42. W 7.....,.....,
ell �1�1�u
6.Is(are)the well(s)ipPermanent or Temporary Signature of Certified Well Contractor Date
Br signing this form,1 hereby certifi•that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or f No with ISA NCAC 02C.0100 or 1SA 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 cops 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:
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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
1 SUBMITTAL INSTRUCTIONS
ZO9.Total well depth below land surface: S (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(td,_00'and 2(100') construction to the following:
10.Static water level below top of casing: la90 i (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: JL4 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: 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.) g
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1JtO Method of test: 04.)6 24c.For Water SUDDiv & injection Wells: In addition to sending the form to
HI
the address(es) above, also submit one copy of this form within 30 days of
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13b.Disinfection type: A Amount: 3 firaoscompletion 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