GW1--05681_Well Construction - GW1_20240920

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
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14.WATER ZONES
Well Contractor Name
FROM TO DESCRIPTION
P c / 0 ft. r;I ft. 5 G-i pin
M
ft. ft.
NC Well Contractor
/-Certification
�Number
�l '� 1� r .45.OUTER CASING(for multi-cased wells)OR LINER((if
ap licable)
l�• 1 `d` VvT► Gr1/'��V) . V .i. FROM
ft. ft. DIAMETER in. $c♦rf'THICKNESS MATERIAL
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Company Name /f� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: W a(4- V a 3 O -
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): ft. ft. in.
• SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public ft. ft. • in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
Industrial/Commercial &Kesidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. 8 l ft- NEAT/E,I�IT„� " PO at 2 i,7' i bs
Monitoring Recovery ft. N ft.
Injection Well: '
ft. ft.
Aquifer Recharge 0Groundwater Remediation
•.19.'SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Ehalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary) '
FROM TO _ DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Coolin�g/Return) [Otther(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: A "'r D p"-at/Well DV ft. ft.
5a.Well Location: ft. ft. 5 't `-,,'" -'a P,—j
ft. ft.
SAGA 7oSEP1-4 ft. ft. SEP 2 2'Z4..
Facility/Owner N e Facility ID#(if applicable)
ft. ft. lr,,`J:;T..1;i il 7.,-.r,';L--fl Ua
�
1 13 1 UIGILgRS T Rom,I ' 2.04" ►.lc ft. ft. G', bi':xlr y
Physical Address,dr� City,and Zip /�
DIZANG1 0 go45.5,g Lf( I -21.REMARKS
•
County Parcel Identification No.(PIN) . V O- . 0 ,.^V n..1 g. "'I'e To
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: DET E i`j"D 1`PT.x Men GASTxI C�
(if well field,one lat/long is sufficient) 22.Certification: �1� r
4.V1 4)331. N "�Qtt 91� �5ao w 1�11.. w�L{‘ N Q�r r�4
6.Is(are)the well(s) ermanent or i--Temporary Signature ofCertifie ell Contractor Date
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: es or ONo with 15A NCAC 02C.0100 or ISA 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 provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.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 I 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: 2(20 (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@20 �nd 2@100') construction to the following:
C.a
10.Static water level below top of casing: ! 3 (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: to 'A (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
nn above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: iZ 01 mui 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) S Method of test: Pu,M 9 24c.For Water Supply&Injection Wells: In addition to sending the form to
f/ '� the address(es) above, also submit one copy of this form within 30 days of
/T 13b.Disinfection type: T H Amount: / 2 0 Z completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016