GW1--06258_Well Construction - GW1_20241021

«;_ I
WELL`CONSTRUCTION RECORD(GW-1) QJ For Internal Use Only:
1.Well Contractor Informat�ijon: O } q�P5;71 ! 7
f. 1!-/t K ) J�0///l 19::WATEkt ZU1VE$.; .. .. :"'.'_ 1,. . .
•Well Contrac or I(lame FROM TO DESCRIPTION °� /9�7
5.
lit 1/ip ft. ft. �� � �c! ! Fa '�Y
ft. ft. ic-& c.P r
NC Well Contractor Certification Number
:15r'OTJTER:CAS1hIG;(fdf'.rtiulii�;ciise0:welis)`OIf:�1iVERi(it'rip1 &i
llciilile):..2,::::,..".•. :.
/ - /� )/ tire. FROM TO DIAMETER' THICKNESS MATER LL
P 1 ®l e � � ; f. 61 ft. /e ;in; r./ (/f! �tik
Company Name
� '16.INNEI3�CASIN•G.:OR TUBMG'(eentli¢rineireli sed,Inolii:>..7:".`,'r :: i.
f (�Q
2.Well Construction Permit#: / D P/ i/ FROM TO DIAMETER , THICKNESS MATERIAL
List all applicable well construction permits(Lel UIC,County,State,Variance,etc.) ft. ft. i in.
3.Well Use(chech well use): ft. it. in. I
Water Supiky Well: I7.S.GREEN:: :'' _. '::..: :;:"'>::._'..., _ ':: ,.. ;
FROM TO DIAMETER 'SLOT SIZE THICKNESS MATERIAL
]_I GeoAgrtheltu 1 DM icntial blic p ft. ft. in.
i Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. tn.
I..i Industrial/Commercial Residential Water Supply(shared) •.zs.GltOTiT: r:'
1•-)Irrigation I FROM TO MATERIAL . EMPLACEM//ENT METHOD&AMOUNT
Non-Water1Supply Well: • 0 ft. aq4i:ft. 89/yreif bn c7 u A 1
s Monitoring l oRecovery R. I ft. C�!n 5 iai' 9' Pip
Injection Well: /'
ft. ft.
21 Aquifer Recharge 0Groundwater-Reinediation
I ••19::SAND/GRA'VEL'PACIE'(ifapplica"6Ic)"`..7;".`: -'..a;`..;:''.t v'<•h'' :.: 1:1Mi;c .1
1:11Aquifer Storage and Recovery OSalinity Barrier FROM- TO MATERIAL EMPLACEMENT METHOD
..I.Aquifer TTst DStormwater Drainage ft. ft. I ,
.i'Experimental Technology OSubsidence Control ft. ft.
1 ;hGeothermal(Closed Loop) I. Tracer •'20::DAILLINGEO:G'(attach.ailditibailsbeels"lfnecessa4).1_:"rc :=:' :ri.::.'
FROM TO DESCRIPTION(color,hardness,sali/racktype,grain size,etc.)
_I:Geothermal(Heating/Cooling Return) IpOther(explain under#21 Remarks) 0.fr. tr. p' ��
a4.Date Well(s)Completed: I P 4(Well ID# ) ft. ft. p . A) 6/ y -T
Sa. ell Locition: 1 ft 91 ft. R Paik ,.i..---‘..F—ii..
ft. ft. L I I.T .j . 1U14
Facility/OwnerB `� p Name Facility/� ID#(if applicable) ft.
-�
16 3 A , r $r�Ar n)- (..hnli,ei ft. ft.
:T-arc �'-
ft. ft. � � -tt . , -
Physicaepss,City. .and Zip { �.0 ice_..
C%eVilJ I '•2'1:1tENIARKSi:: '. ...,;... ..: •,;•:I.�„ .;.;' 'Yt.:..:::t,... .,;::yT/.j./,.,
County ( Parcel Identification No.(PIN) ' )f V�/6'T .( (• 'pbJ,('' /!v!-� I
5b.Latitude land longitude in degrees/minutes/seconds or decimal degrees: L)9"5 /A c , j- ) ' 1- "L Y.
(if well field,oo�z�e lat/lon�g is/sufficient)� 77 .44)
f ) 22.Certification: 1
(/Ir'Y j /'1'V / NYC, `7��G� W 1� on �O -41 4
6.Is(are)the'well(s) manent or Temporary
Sig�a of Certified We tractor Date
er
By signing this form,I he eby certi that the wells)was(were)constructed UP accordance
7.Is this a repair to an existing well: ElYes or EEK with 15A NCAC 02C.olop or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,Jill out known well construction information and explain the nature of the copy of this record has ben provided to the well owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
I You may use the back of this page to:provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,linty 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:p (2, P (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii different(example-3 200'and 2Q100) construction to the following: I
10.Static war r level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is bove casing use"+" 1617 Mail Service Center;Raleigh,NC 27699-1617
11.Borehole d$ameter: (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 comple'bn of well
12.Well construction method: fT' 71I7I/ construction to the following:
(i.e.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) I_ Method of test -di' 0"/J0/ 24c.For Water Suauly&Injection(Wells: In addition to sending le form to
the address(es) above, also submit tine copy of this form within 30 days of
13b.Disinfection type: � /.j.-/r Amount: completion of well construction to t le county health department of the county
1 where constructed.
i
Form GW-I ti North Carolina Depardnent of Environmental Quality-Division of Water Resources Revised 2-22-2016