GW1--05425_Well Construction - GW1_20240909

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
C/cA vi O rtf 14;WATER?'LONESr ;:i $R ray:s Yw? .r} Es�l
FROM TO DESCRIPTION
Well Co rector Name Nft, ft.
q6 / i ft. ' ft.
NC Well Contractor Certification Number
^ 15 IUT RCAS[NG061imultkiseb4al,Il1g0RLYNI}R(ILaiiiikible)- I
/ �//l r / FROM TO DIAMETER THICKNESS� MATERIAL�
s V l l' CA it� I O 1 t� l 'C' t ft. C6 4, ft. 6.i25 In. 5t✓2 (V c
Company Na c y �j 4 1'tj INrIER C 4'$fNC Ott;T BI11 ( w ther}naliCloigd4l o�FS�
2.Well Construction Permit#: SW.40 2L' —O 3 6 I FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UI County,State,Variance,etc.) ft, it, In.
ft. It. In.
3.Well Use(check well use): 1 � � 1
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft, In.
Geothermal(Heating/Cooling Supply) .,;'Residential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared) ,1$i;GR0UT: ':.-. :'t I R°ax `r`az rti"•`` -i
•Irrigation FROM TO MATERIAL 1 FMPLACEME T METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 2 Q ft. r3e, to i c, , oV S_pp U C,d
Monitoring IN Recovery ft. ft. 0
Injection Well: It, ft. —
Aquifer Recharge Groundwater Remediation -:19:SAND/GRAYEt;1j f tIC'(If appllei43I 3:=` ``" 4 v 4 T 1
Aquifer Storage and Recovery [Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology [Subsidence Control ft. rt.
Geothermal(Closed Loop) DTracer 0:.)RIh4WG'1s01;r(gti'ao4taddfHonia'lihaeyt(fnece9 airy) ;=-W M.Y.
PROM TO DESCRIPTION(color,hardness,toll/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) 0rt. �'l4 ft. C,�a�
4.Date Well(s)Completed:OV2072y Well ID# g6 ft. L/OS ft. &rarer
ft. ft.
5a.Well Location: — r—r--�
it. It. ' � t
AGV v{, �ofte, l�G . ,,L, ✓,_
Facility/Owner Name Facility IN(if applicable) ft. ft. — 1 C n Q
S 202
112_ t3;l/ Ck-e k gd. ft.. ft, Cr 1
Fir sical Address,City,and Zip
g rt. ft.
County Parcel Identification No.(PIN) _ .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: —(if well field,one Iat/long is sufficient) 22,Certification:
35. 1z`i6/ N .22-.16/ 52 w oFr/ / ,
"ipermanent or Tem orar Signatur fCertified Well Contractor Date
6.Is(are)the well(s) 7t P y
By signing tnis,jorm,i heresy ceri f v that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or No with ISA NCAC 02C.0100 or 1JA 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 provides'to the well owner.
repair under 1421 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 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: e t/5 (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@200'and 2@100') construction to the following:
10.Static water level below top of casing: 7 O (ft.) Division of Water Resources,Information Processing Unit,
If water level Is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection 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: gCJiri r/ 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 Method of test: 44 r 24c.For Water Supply & Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:(//c/O, vie, Amount: Ci Gigs completion of well construction to the county health department of the county
where constructed.
Form OW-I North Carolina Department of Environmental Quality•Division of Water Resources
Revised 2-22-2016