GW1--05717_Well Construction - GW1_20240920

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Print Form
WELL C.,NSTRUCTION RECORD (GW-1) � For internal Use Only:
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1.W II Co tr. tor Info nrion:
1 �� t' '�`/�//!� 14.WATER ZONES I I
Well Contractor Name FROM TO DESCRIPTION
• Pt -2 t70t. . 7s-rt, �!) ► q• f7Vt
_ ft. I
NC Well C tractor C rtificati Number '
/� & ,// ( IS:OUTER CASING(for multi-cased ivells)OR LINER(if ap Unable)
I1�= t77' � � �/ //1� FROM TO DIAMETER ' THICKNESS MATERIA
l�r 111 •--f�/� ft. 'ft. I, in.
Company Name 1
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Cti•struction Permit#: _? q / r FROM ' TO DIAMETER THICKNESS MATERIAL
., List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) Q ft. [.ft. j- Yq in. j )�,j-•% ? [/ .
3.Well Use(check well use): ft. ft. L� in. 5 S I
Water Supply Well: 17.SCREEN• • I
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
311'Agricultur4 DMyrricipal/Public ft. ft. in.
11I Geothermal;(Heating/Cooling Supply) JResidential Water Supply(single) ft. it. in. '
liI IndustriaUdommercial. D Residential Water Supply(shared) 18.GROUT
.1 Irrigation 'I FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: rt. J11 j �Cjr Cr 4i-/7`/ I-7 f
Monitoring Recovery ft. fr. I Injection Well: ft.
*Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable),• Aquifer Storage and Recovery OSalinity Barrier FROM TO 1 MATERIAL EMPLACEMENT METHOD _
i° Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology • OSubsidence Control . ft. ft.
Geothermal'(Closed Loop) DTracer 20:DRILLING LOG(attach additional sheets if necessary)
r Geothermal(Heating/Cooling Retum) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,solVrock type grain size,etc.)
r t, it. L? ft. t^1//i C 6 /./r'r y5
4.Date Well(?Completed: to-"e r Well ID# 0A1/i + ft. rt. „ 9 f.; Ao, `
Sn.Well Location: cilaft. f' ft. / �1 �f� 4��,���
Facility/Owner NamcE4jl4e.,-4.[ j//� Facility iD#(if applicable) ���� 6 ft. R. !, tJ
Physical Address,City,and Zip +il/<e Cc$/ . 4,c4rs 7/O ft. It l, r'`;.• -.•' ','V
21.REMARKS • " 4--.1 0...i
�6 i YJ J�� '-/7 —
77.7 i. SEP 2
County • i Parcel Identification No.(PiN) 0 �r?d I .
Sb.Latitude aid longitude in degrees/minutes/seconds or decimal degrees: tr.`"-"- -,
(if well field,one�lnt/long is sufficient) w` t
/f 22.Cere'cation: G=-•�t;,a:,x;
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`�! t( /%'- _N Ci--'.�: .`-� '274 W //�/ .� &1* '� _��( 7
6.Is(are)the wells) . ermanent or JTemporary Signature of Cer�(fied Well Contractor Date
it By signing this form,I herd) P certifj•that the well(s)was(were)constructed in accordance
7.Is this a reppir to an existing well: [� es or I o with ISA NCAC 02C.0100 r ISA NCAC 01C.0200 Well Construction Standards�rtd that a
If-this is a repot);fill out ktrorwr well construction inhumation and explain the nature of the copy of this record has been powner.ovided to the hell owner.
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repair under#21 remarks section or on the back of Vs 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/�iis needed. Indicate TOTAL NUMBER of wells construction details. Yot1 may also attach additional pages if necessary.
drilled: ///— SUBMITTAL INSTRUCTIONS ''
9.Total well depth below land surface: 92 S (it.) 24a. For All Wells: Submit this Form,within 30 days of completion of well
For multiple wells list all depths ifdiffere'(examp e-3 200'and 2©100') construction to the following:
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10.Static water level below top of casing: '?,3 ' (ft.) Division of Water Resources,Information Processing Unit,
If water let'..,is above casing,use"+"1 G 1617 Mail Service Center,Raleigh,NC 27699-1617
I1.Borehole diameter: Ys • (in.) 24b.For Infection Wells: In addition"to sending the form to the address in 24a
A above,also submit one copy of this form within 30 days of completion of well
12,Well construction method: p-/k tc016 }/ construction to the following: j
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(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Pro ram,
• FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cent Pr,Raleigh,NC 27699-1636
I 13a.Yield(gpm) r 0' Method of test:/'' Z"/'7 24c.For Water Supply&Infection Wells: In addition to sending th form to
the address(es) above, also submit o e'copy of this form within 30 days of
I �' ? .s;- G) completion of well construction to the county health department of the county
• 13b.Disinfection type: (I hie/JAIL-1-/./J�- I Amount:f;, l
where constructed. I
' Form GW-I 1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016