GW1--05669_Well Construction - GW1_20240920

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well contractor Infor ation: i/�5;f I
14::W,ATER ZONES 't.i. .
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
ft ft. i jr `2 ri) '44 5
NC We Contractor Certification Number 15r'OUTEItCCASIt4G'(formulli cased: el(Is)C/OlR1;IItfEIt(i£ap llcatiie}:.- c:
/� t f� ( >)� FROM TO DIAMETER THICIINESSS MATERIAL
CJ/ # nil-P6 :/Y t� Oft. ft. [a. 7. J ✓T/P
Company Name n 7 1/ t
/4 2 612 16.INNEl CAS _OR TUBIIQG'(Qeofhermel:closed-loop)" .:7"`
2.Well Construction Permit#: / FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(I.e.U1C,County,State,Variance,etc.) ft. ft. I in.
3.Well Use(check well use): ft. ft. !in.
Water Supply Well :.17:;SCREEN r .-:,..-, t ..2. .r,:'r. .:.:' ,., .
Pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public O ft ft. in.
f Geothermal(Heating/Cooling Supply) °Residential Water Supply(single) ft. ft. in.
In.ustrial/Commercial °Residential Water Supply(shared) •rz&i6RO1I'I W:. , .... a' _; .''•:
'gation FROM TO MATERIAL - EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: C ft. 3d ft. iVOG / IV
�r
%Monitoring Recovery ft. ft. �j��-/A f/� 7L7�®
di-
Injection Well: ft ft. /
Aquifer Recharge Groundwater Remediation 19',SAND/GRAV.EL`PeI kllf ajibtice6le) _1 q"; , ;? _ ,,;
Xi Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
X Aquifer Test 0Stormwater Drainage ft ft.
it Experimental Technology }Subsidence Control ft. ft.
II Geothermal(Closed Loop) 0 Tracer •'20tDItII:LAYGEO:G.'(attaelf:nddiH'o"misheeta'.if lfiessaiWe•'^ a .'. , _.
FROM TO DESCRIPTION(color,hardness,son/rock type,grain size,eta)
_I Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) / ft. 6/ ft Q 2� !.1 hi a�
4.Date Well(s)Completed: d i) �l-Well ID# 14 G/ ft /� ft 8v air .t
5a.VX
elll)Location:f j))J G t"l ft �v ft �:�A1/+�'�)ljy,/ �// `5 j sue,
Poi re, �rr v p ft. ft �7�• 5T4j1lIi" e%J4 1..f 2 °�i 1_J
Facility/Owner Name - J�Facility ID 1(if applicable) ft ft' C t i p )g
CAP/4)4R 1?I,(A}.c,cI 314 ft. ft J C r] UL`t�
Phys cfl Address,City,and Zip 41 1,1911P4/ p/yr j P ft ft I I r' . .. ,f 7 rr, r a x,1 Ar
S21c REI41ARKS,c.:. t-.� •. ,.-•iw. .t;2 it- ,1Kl,,i-(J,F .� :
County Parcel Identification No.(PIN) 6 'FA/T/t& �`e'-'ry el T L `
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) f l 22.Certific "on:
'3'X 3 U'isU N /J e•�J'e� //CJ W au.../ ! /✓,(iiPi��',i, e 41
6.Is(are)the wells) ermanent or °Temporary Signature of Certifiedell Contractor Date
By signing this form,I hereby certl that:the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: X Yes or PI< with 1SA NCAC 02C.0100 or 1SA NCAC,02C.0200 Well Construction Standards and that a
Ifthis 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:
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
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9.Total well depth below land surface: v� (ft) `
p 24a.For All Wells: Submit this farm within 30 days of completion of well "t
For multiple wells list all depths ifderent(example-3Q200'and 2I a@100') construction to the following:
10.Static water level below top of casing: / (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level Is above casing,use"+" . 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 246.For Infection Wells: In addition ito sending the form to the address in 24a
1/1��, -.77J above,also submit one copy of this!foim within 30 days of completion of well
12.Well construction method: // construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: _ 1636 Mail Service Center,Raleigh,NC 27699-1636
` iy//,/ id/
13a.Yield(gpm) L�0 Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
Hi
ll
j the address(es) above, also submit i one copy of this form Within 30 days of •
r1 ! I
13b.Disinfection type: Amount: C� `"1' 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
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