GW1--06252_Well Construction - GW1_20241021

WELL CONSTRUCTION RECORD (GW-1) For Internal i_L�On..Iv-_
1.Well Contractor Information: I:
-S c>S"JJ\ U 1/� e5 e 5 14.WATER €ES=`- .."y?.,�lli.E- 7 :Y.'6: t_4 _tVD at is _' Pw'
Well Contractor Name / FROM I TO I DESCRIPTION
L\\ i PI - ft. J rt. !
Ir
ft. ft. ;
'NC:Well Contractor Certification Number 15.OU1'L1 rASELG.(for.'iunilh?E3 eraaiel` Cf1Z+ NAit;(t "'4ljl`e) «' °r:?r-,.a.
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i FROM TO DIAMETER THICKNESS MATERIAL
1 �(t/c�SJt/1 Ll/c'11 a i 6 (� 0s5 rt. rt. j in'.
Company Name J
16:,.INNERCASTftG;01t 4111•01 `51gTa'8v 12 p)+ t&V. hVi IPt ..:k%.
2.Well Construction Permit#: FROM TO ' DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,'County,State,Variance,etc) lJ�\ ft. 16(‘ ft. U in. SoG\ ior/G -
3.Well Use(check well use): ft. ft. I' in. V V
Water Supply Well: 17:-SCREEN }a, ` ,h fiAigg k A6:::Wr; i° g '.i' iNiO`M:4g$� �.tr
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
'Agricultural 0Municipai/Public ft- rt. 1n• s 4O park
IG�b I�� �I t , uao �� .
Geothermal(Heating/Cooling Supply) 12<sidential Water Supply(single) ft. ft. ill. I
Industrial/Commercial Residential Water Supply(shared) ig..GROU,T ' �'i`t` lk I;r,.,.raM ,h fix, lit -=chi.F i,
.. Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 0 ft. t. to J,� ,ie ,/))L- )Li 6
Monitoring -DRecovery ft. ft. p �,! V
Injection Well:
ft. ft.
Aquifer Recharge 0Groundwater Remediation
19:SA1VD%GRAVELPACK(lfap s&cab1e}'`n1'..` itu gi4:r` l.M':Y r:yam" #7
Aquifer Storage and Recovery 0Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stonnwater Drainage / 60 ft. t 776 ft. 4-g Se.n
Experimental Technology 0Subsidence Control ft. ft.. l;
.Geothermal(Closed Loop) 0Tracer 20.DRILLING1OG(iittecli.addiiroual i[iteees'sii1OM z', 4W ,_"` W
Geothermal(Heating/Cooling Return) DOther(explain under 1#21 Remarks) FROM TO DESCRIPTION(color,hardness.soil/rocktype,grain size,etc.)
ft. ft.
4.Date Well(s)Completed: /0—`:1-24 Well ID# ft. ft. f/
Sa.Well Location: ft. t ft. r ') e eta
... S I c t_.0 C ft. ft. "c'--Z....a i...,- t i3l I,.,Ls
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ft. ft. O C I J L r
La6.5 ►\;c,. �e)_ f't`✓ 4,)�t c'7`d6S
Physical Address,City,and Zip ft. ft. Il i-:v; rg .f.-.7.P.m ,.Y2,;Li j;PA
21,I2EMARICSO. Ai 1i ,.,s`4.a_il li i, .;k6*.ii,t1,0:R-I !
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ''
(if well field,one latJlong is sufficient) 22.Certification: 1 ,
5,70 DO CD N -76 . ' 3373 w Id- -.2y
6.Is(are)the well(s)^AiPermanent or Temporary Signantr f Certifie ell Con[ractorf Date
Sr sign tg this,/o t.I hereby certify that the well(S)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes oro with 1 A:VCAC 0-C.0100 or ISA NCAC 02C.0200 it'ell Construction Standards and that a
If this is a repair,fill out known well construction information and explain the itciture 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 tray,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
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9.Total well depth below land surface: l 7 (ft-) 24a. For All Wells: Submit tliis°fonn within 30 days of completion of well
For multiple wells list all depths if different(example-3(a1200'and hd@100') construction to the following: ,
10.Static water level below top of casing: I
0 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"—" 1617 Mail Service!Center,Raleigh,NC 27699-1617
7 it
11.Borehole diameter: '7 �' (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: V\
c)I r above- also submit one copy of this form within 30 days of completion of well
MP`/ 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) ND Method of test: eur<y r- 24c. For Water Supply& Injection Wells: In addition to sending the form to
the address(es) above, also subini't one copy of this form within 30 days of
13b.Disinfection type: H ( H Amount: I las, completion of well construction toi 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