GW1--05337_Well Construction - GW1_20240906

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.W 11 C . tot•Infopm:f)ti
/ /�� /// 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
(��•gg- P -) .. rt. ft. i
NC Well C tr ctor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if rap licable)
JJJ, 97 y
ill g -g// 1/5):7 - /V/ FROM AS DIAMETER THICKNESS MATERIAL
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop) i
2.Well Co:.struction Permit#: =.4 f r FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.Lilt,County,State, Variance,etc.) p ft. f irn ,/ ft. 6 iII. ` S 7)-- (;,J i- A,It
3.Well Use(check well use): ft. ft. in. . '!-L,
Water Su Well: 17.SCREEN
Supply FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural DMunicipaVPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ff. in. I
Industrial/Commercial !Residential Water Supply(shared) 18.GROUT �"
"rigation
FROM TO MATERIAL EMPLACEMENT METHOD&AMOu AMOUNT
Non-Water Supply Well: j.' ft. igL`/IiZ'd%i,%t ��I��`/✓' ���
Monitoring Recovery ft. - ft.
Injection W�11: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(If applicable)
D
Aquifer Storage and Recovery
Barrier FROMTO MATERIAL EMPLACEMENToll/rock type,grain size,etc.)METHOD
Aquifer Test
Experimental Technology
OStorenwater Drainage ft. ft.
DSubsidence Control ft. TO
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets If necessary)
FROM TO DESCRIPTION(color,hardness,s
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
rr') ft. / 'r ft.
ff)/). ^ •' i 4....
4.Date Well(s)Completed: •.e .0 Well ID# ( i ft. r/, ft. .A/' /Le.1l�f,4�/ ,�� °4;;;2
,tft. -
Sa.Well Location: =- : -6-0.° ; .s'i c'�i,% 2/: 1 > (i(° /t.
r ft. ft.
Facility/Owner Name Facility ID#(if applicable)
", ft.a ':C-' ft. 1 / �� / � ,
'°/.-•fr '.1 r :`i 1/(I"l xl i 4..S Ai( ..A2,Sh F'(,/::r` 1 ..�4 L.. . ' '
Physical Address,City,and Zip ft. rt. SEP
e 1 n.f'. �.,iyf -j-(- l 21.REMARKS 0 V 2024
Count ./ ••• rf Parcel Identification No.(PIN) s,r^
y l Ir.IG:r.r.i.f+1 1`:.:',; ji'te
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: D'Nf.t.'303
Olive))field,one tat/long is sufficient) 22.Cert. cation/:
! d:�i / :•7' f't A_ N i I f iz 7 irj j'%1r W /�/�(/ 7 /,
6.Is(are)the wells) Y lsermunent or Temporary
Signature of Ce led Well Contractor Date S
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or peso with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repa(r,Jill out known well construction information and explain the nature of the
copy of this record has been provided to the well owner.
repair under#2/remarks section or on the hack of this 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,l GW-1 is needed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages if necessary.
drilled: ' A. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ';'t:. 4:' (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For nurltiple wells list all depths if different(example-3@200'and 2(41100') construction to the following:
7 (ft.) Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: b , 1617 Mail Service Center,Raleigh,NC 27699-1617
lJunrer lee is above casing,use"+"
11.Borehole diameter: _.. (in.) 24b. For Injection Wells: In addition to sending the form to the apdress in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: i f' +'s?I14'-d41- ✓ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control 1lrogram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i ) "' r;' ' i' 24c. For Water Supply&Iniection Wells: In addition to sending the form to
13a.Yield(gpm) Method of test:
f ""e
the address(es) above, also submit one copy of this form within 30 days of
r as•: completion of well construction to the county health department of the county
13b.Disinfepon type: fz,�l+:��°/=/ "-' Amount: jr.,`-')‘-.. where constructed.
Revised 2-22.2016
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources
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