GW1--05710_Well Construction - GW1_20240920

Print Form 1
WELL CONSTRUCTION RECORD(G�Wi-1) For Internal Use Only:
/
1.Well Contractor Inform on: '--7 /,03#29,0,
la.WATER ZONES
Well Contractor Name FROM TO _ DESCRIPTIONft. 1� ] /
; P`)9 ft.ft.
ft �/L �� �(' L ��L
NC Well eC^ontra±ptor Certification Number/� y� s 15.OUTER CASING(for multi-cased wells)OR L) MRc(if ap licable)
r/! %ei -i r_l (-- .3 ri i FROMO
ft. T�17 ft. D�7�// lER n. SUCI I .
C2.W ll Name Iv t- 16.INNER CASING'OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 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
Water Supply Well: 17.SCREEN
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
Agricultural ['Municipal/Public ft. ft. in.',
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. in.I'
In strial/Commercial Residential Water Supply(shared)
18.GROUT
i' •(r,ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 4 ft. 0T l"fJ 1 PA fP kt bigi 5
Monitoring ['Recovery ft. ft. 0.),Y/ �97h7 ' Alp
11/
Injection Well: ft. ft. J
_ Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage ft. ft.
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) ['Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ID Other(explain under#21 Remarks) , FROM TO DESCRIPTION(color,hardy solFrock type grain size,etc.).
9�'/ � n ft. 3 rut. P 1�'e�/o I1t d aiy
4.Date Well(s)Completed: Well ID# ' ft jir ft. 1,L:l G
5a.Well Location: �j r�j y� V
ft. 39p ft. ( ).,9iy;1 ((r2 „/rw
lit �le 2�/!/T/// ft. ft. j "`
Facility/Owner Name Facility ID#(if applicable) ft. ft. �'^ n s Y;-,r,.,o p, r_,
r A ? 3$#.id/elaipe a r�.'....,. . /
1 (�gny �� �h ! ®� ft. ft. C`(� a,.o: �•r!I 8.��.r
> ,e. r / 6/ �' ft. ft. J C r 0 /I i�Q
Phy �._- itv and _
_ � iN j- 21.REMARKS ..
County Parcel Identification No.(PIN)
Irwd:?-4ie�� Prr:(oot3tag l.Ipl`i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
33f,374, 9 N 8P, h)3hi w la
�� 9- ' �6.Is(are)the well(s) ermanent or ['Temporary of C ed Well Contractor Date
7.Is this a repair to an existing well: DYes or
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
'o with 15A NCAC 02C.0100 or 15A 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:
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 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1� SUBMITTAL INSTRUCTIONSI
9.Total well depth below land surface: 3od" (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 00) construction to the following:
10.Static water level below top of casing: f/an (ft.) Division of Water Resou,ces,Information Processing Unit,
If water level is above casing,use"+0' ( 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: llD t'I r(in-) 24b.For Injection Wells: In addition to sending the form to the address in 24a
], p above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: (� T,/�`}^ construction to the following:
(ie.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
13a.Yield(gpm) 45-P Method of test: 7 24c.For Water Supply&Iniection Wells: In addition to sending the form to
] the address(es) above, also submit'one copy of this form within 30 days of
y�j
13b.Disinfection type: 14/ ' t Amount: / P.Z. completion of well construction to ithe 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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