GW1--05968_Well Construction - GW1_20241009

WELL CONSTRUCTION RECORD(GW-1) For Internal Use only: _ ""
1.Well Contractor Information:
1 f'r./J&9- - -7 1V-e c-G 14.WATER'7ANE5
Well ntractorName FROM TO DESCRIPTION
'tQ f(a -A /so ado fL 5,O c
ft. ft.
NC Well Contractor Certification Number
15 OBTER CASING multi-cin d welis),OR.LINER(if aP liaiWe) c
6 L L1 t /2d / � tWi LL(L Q ft. y ft. GP im ROM TO DIAMETER bDII �MCKNESS _C
:16:INNER:CASING'ORTUBING"(geothermal closed-loop) = .,
2.Well Construction Permit#: / - FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UiC,County,State,Variance.etc.) ft. ft. ; in.
3.Well Use(check well use): ft. ft. in.
iT SCRII,T1, n....
Water Supply Well: FROM TO DIAMETER SLOT SiTE THICKNESS MATERIAL
Agricultural OMunicipal/Public g, g, lin.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) tz ft. in.
Industrial/Commercial •DResidential Water Supply(shared)
Irrigation FROM. TO MATERIAL EMPLACEMENT METHOD&AMOUNT
•
Non-Water Supply Well: 1t. ] IL
bR ixi;
a s CI ��n[ - d 1 l
Monitoring~ ['Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL'PACK(if applicable)
Aquifer Storage and Recovery EjSaiinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage ft ft-
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer `-20.-DRiLLINGLOG'attacKadditlon'alsheetsifneeessa )
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DFSc oN(cabr,hardness,soiFrock type,grain size,etc.)
-a 6 - a '�" Oft , ft d C/f7
4.Date Well(s)Completed: Well ID# '7 (0 ft 2 9 ft' �y/'.'`w**/
5aa..Well Location: / s t77(/�1 7? as f ft. G'yr/i+
i► j *Le0/0' /o
0~ , 30 J 7 ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. . : —'t: .: .,; ..,'\
p 3 7,4'1 ti$4,fd SRO y�o?ei ai 1`f ft. ft - ._. ..t..:-. ?ZR-4-.,L
Physical Address,City,and Zip ` ft. ft. 0�C ! 0 V 2024
C47/s,/7 . .7 77 Q. (J/Q f 7 7.2 21.REMARKS .. ..
County Parcel Identification No.(PIN) l-'t rt
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r�
(if well field,one lat/long is sufficient) 22.Certification: Q.cc�� 14 )J— A
27-lea5 N 87`0?/5/' W
6.Is(are)the wells) Permanent- or- ry-Tempora - ._ _ ofCertified WetlContsactor Date
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: jYes or NO with ISA NCAC 02C.0100 or ISA 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:
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: SUBMITTAL INSTRUCTIONS!
9.Total well depth below land surface: 0 S (ft.) i
For multiple wells list all depths ifdderent(example-3 go'and 2Q100) 24a.For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing: 3,5- (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
1
11.Borehole diameter: G I.1. (in.) 24b.For Injection 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: f*P-4--Clt.AA.1 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) Se Method of test: �gi-17.z-g- l'r.c4 24c.For Water Supply&Iniectiion 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 4,4 Amount: COX completion of well construction to the county health department of the county
where constructed.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resour j Revised 2-22-2016