GW1--06257_Well Construction - GW1_20241021

1 Print Form .
WELL C INSTRUCTION RECORD(GW-1) For Internal Use nly: 1
1.Well Coa ractor Information: .; )
/3ii'r l t .14.=waTF zoNEs;t r.:a; ;- . .
t FROM TO DESCRIPTION
Well Contractor Name_ J._] -4 ft. .--
lit er !P> .9c' /F1.) )c3�/,+
. ./ ft. ft. / i-0 37p 5
NC Well Con i ctor Certification Number f'
4 I _ Y-I5ii011TER;CASING.Ifor muitiissed`welis)'AR LINER'ftf air lienble).:,. , -
P F/� 42.
e //1 Si, ,!'I.i /s FROM TO ..,. D I TRICKINESS
Company Name
�(� C� 0 rt. •5`f m L !in. 1- atWe._�/ 16INNER`CASIN'GTORTOBING`(teattiermefclosed-loop)
2.Well Construction Permit#: 1.���/� � FROM TO DIAMETER THICKNESS MATERIAL
List all applica a well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. 'rn.
3.Well Use(check well use): ft ft. in.
Water Supply Well: AV SCREEN' ,:.-,I =4: -:._:`. . - - -.
FROM TO DIAMETER ,SLOT SIZE THICKNESS TERIAL
Agricultural Municipal/Public ft. ft. in. ; i. P('.•
Geothermal(Heating/Cooling Supply) !Residential Water Supply(single) it. ft. in. ,
Industrial/Commercial OResidential Water Supply(shared)
'18iGIFOUT -. _ - - .'Of -
,il, *gation FROM TO .- :MATERIAAL., •EM�PryLAC�EMENT ME O)&AMOUNT
Non-Water Supply Well:. ft ft 4.4�1 fj l`i �/�1 /1y�/ ��9�' .
Monitoring J Recovery tt ft.
Injection Well:
Aquifer Recharge Groundwater Remediation ft. ft. 1!'/ V c' l�!/
I� <r19 SAND/GRAVEL PACK'(if applicable):-
Aquifer`Stoilage and Recovery �1Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer 20.DRILLINGLOG:dtthch additlouel'sheetsafnecess 1'.. '_ .
of FROM TO (I DESCRIPTION(color,hardness,soil/rock types groin size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ro ft ,ft. 3'
q-: ,d�d /'' 24 ft a, rt. ��. . r��-de/i
4.Date well s)Completed: ell ID# ����
5a.Well Location ] ft. 5 ft. -
/14jA�'f 61t 3*.P/ PIA)/4 ,f"l f` /SIR fL :�1 /e/LI �'le.
Facility/Ofw�neriName Facility ID#(if applicable)
licable,)h
ft. ft.
q / / y l �I'' .7- l /?l/' / L ft. ft. i 2
Physical Addres4,City,.and Zip ft. ft
County I Parcel Identification No.(PIN) 1 O r 1 2 I. t024
5b.Latitude and longitude in degrees/minptes/seconds or decimal degrees: I +I r`=:; t
(if well field,one lat/long is sufficient) I "•:•"•- ;I
� // (� .�ryJ/��, �,/'7 /y 22.Certification: -. -
! "�d ! 7P 74� 3 !mil 7 3 1 w i s i.�..J i- �1 2/y .%:3:i
6.Is(are)the wells) ;Permanent or Temporary Signature of C„„17,17/1e ed Well Contractor I' Date .
By signing this form,I hereby cert fy that,the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ro with ISA NCAC 02C.0100 or 15A NCAC'02C.0200 Well Construction StandaEds and that a
If this is a repat 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:
You may use the back of this page to provide additional well site details or well
8.For Ge'opr�be/DPT or Closed-Loop Geothermal Wells having the same
construction,Only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: � II SUBMITTAL INSTI CTIONS
9.Total well depth below land surface: f -71' � (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdUerent(exanmle-3@200''aand 2@100') construction to the following:•
'
10.Static Water level below top of easing: 7 ? (ft.) Division of Water Resource,Information Processing Unit,
If water level is above casing,use'+' 1617 Mail Service Center,Raleigh,NC 27699-1617
1
11.Borehole diameter: /t4 6. (>l.) {n 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well a instruction method: iy`�1 /K idT.i !� above,also submit one copy of this!form-within 30 days of completion of well
/ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) p
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLYp� WELLS ONLY: , 1636 Mail Service Center,Raleigh,NC 27699-1636
in ''T Method of test y� l
13a.Yield(gp ) ,7 /--/ I/ 24c.For Water Supply&Infection 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: 0//f Amount: / 04 completion of well construction to the
e county health department of the county
where constructed. I
Form OW-I I North Carolina Department of Environmental Quality-Division of Water Resources ,H,
Rev!ed 2-22-2016
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