GW1--05340_Well Construction - GW1_20240906

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WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor Information:
(oi Y I 43 uto10 14.WATER TONES
Well Contractor Name FROM TO DESCRIPTIONZt I 1% 0 ft. C 402511' 12. ifyl
� ft. ft.
NC Well�CoOntr�Aacntopwr Ce{rt��ifi7cta/t�ion�INumber
� �I ►(`� (} r 15.OUTER CASING(for multi-cased wells)OR LINER(if a cable)
�j�Y`_- "e I�i r "1 YIX�✓, W'C A-+ 1 uny,Ltil (ilt. PRRt ft. O ( fit. Dr/t t rt G in.IAMETER THICKNESS MATERIAL
Company Name IN 1t eo !f/��(�ll C
/\ q a 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: j b L. W 13 ~LID 1-/ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C.County.State, Variance,etc.) ft. fL in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SI7E THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidcntial Water Supply(single) ft ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT-
Non-Water Supply Well: 0 ft. 20 ft• n yrilit,-,njt
Monitoring Recovery ft. /� ft. L
Injection Well: ft. ft.
Aquifer Recharge 0Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stonnwater Drainage ft. ft.
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) Diracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) 0 ft. C 1 ft.
S , (JI. t
4.Date Well(s)Completed: H i Zu Well ID# 5' ft. + ,t4c ft• 'E,
5a.Well Location:
ft. ll� ft.
s1 r�d a� ft. ft.
Facilit cr Name
lel ��p a �,( i�Facility ID#(if
applicable) fit. fit. F w}.N l,,j 1.. Y-
iUl 1 tl.11 Cd�VC, Iry " Vufl.tif`LY vilil 2,3131 ft ft. r+`Il, V (�L.�
Physicalc Address,City,and Zip ft. ft. S E P 96 20?4
r y�cr.i� t G1i 5""�j 25 t47S 1 21.REMARKS
Inionnolierl Form U r
County Parcel identification No.(PIN) 0G
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3.Jwe• 71 N -gv•SJZ W (aJ Dial,/
81)412-L1(
6.Is(are)the well(s))Permanent or [)Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certifi,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [JYes or ONo with ISA NCAC 02C.0100 or iSA NCAC 02C.0200 Well Cnrtstntction 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 ?W-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
dolled' n� SUBMITTAL INSTRUCTIONS
t_.Y 9.Total well depth below land surface: L-15 (fit.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjerent(example-3(0200'and 2(a)100') construction to the following:
10.Static water level below top of casing: 43 ) (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: (.0(f'-i (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: 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) 1 L.-• Method of test:1 6 24c.For Water SuDDiV&injection Wells: In addition to sending the form to
�y��� r1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 1I I I 1 Amount: [ILO J,jS completion of well construction to the county health department of the county
where constructed.
Form GW-t North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016