GW1--06370_Well Construction - GW1_20241025

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information: i�Q )
' -er jeot- - LVzCLG 14.;WATERZONES --r__ :. .
We11,p6ntractorName FROM TO DESCRIPTION
- c-. 62 fa —A 0 rdo' Gig`
NC Well Contractor Certification Number
�] /� 15."OUTER CASING(for atuld,eased.wens)_ORLINER(if tip"Itetible) s; 1 -
r ��1t,n„v �p ei I c, FROM TO D TER THICKNESS MATERIAL
�r5 G�Q1l(!?� r �CC���77DJJUt CAL 0 R. jt•
/3ti ? 16 INNERCASOR:TURIN eothern al:closed400p) =,' -`'
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable lie construction permits(i.e.UJC.Countyy,State,Variance,etc.) il. it. in.
3.Well Use(check well use): ft. iw in.
Water Supply Well: <, • ,.:_,. ,. ,.,._.:> _.•-
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public ft ft, in.
Geothermal(Heating/Cooling Supply) ¢� '-'dential Water Supply(single) ft ft. in,
Industrial/Commercial 'QResidential Water Supply(shared)
18 GROUT :; '--
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 37 ft. 19;(l�i ne 'our m ec;_ id)
Monitoring ORecovery ft. ft.
- Injection Well: R ft.
Aquifer Recharge ()Groundwater Remediation
19 SAND/GRAYEL'PACIK(If applicable)..
Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage it ft
Experimental Technology ®ISubsidence Control ft. ft.
Geothermal(Closed Loop) ®Tracer 2o.DRII.I IIVGI OG-(att.J,additional sheets ifnee ry)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiVrock type,grain size.etc.)
4.Date Well(s)Completed:/(/ L f,y Well ID# Sp q57 R c,/'- 'T
5a.Well Location: cc? n' /kQ l " ",
l ft. ft
/174,4 r hrf 4 a s/1� rt -
Facility/ Na Facility ID#(if applicable) ft. ft. .';L ...'c.:'..; '•r ...,,I.,
1/GI a/(/ // /4/ 4j�.r., 2J7 ft ft. ocT ' 2024
Physical Address,City,and Zip ft ft.
6e-c7.- 117 257 7 7, 70
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21.REMARKS lr t`: r` , `
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: cc�� r�
(if well field,one latllon is sufficient) 22.Certification: oe IQ5 Q. - A
3S'c2.7 ..�YT)N of/ 7 92C'% W � 7 l;i /d� '
6.Is(are)the wells) Permanent or Temporary _ • ,, ofCertified Well Contractor Date
By signing this form,J hereby cert that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: 11 Yes or Fall<r with ISA NCAC 02C.0100 or NCAC 02C.0200-Well'Constnrctlon Standards and that a ,-
If this 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.
wed' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 20 (it•) 24a. For MI Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdif Brent(example-3©200'and 2Q1001 construction to the following:
10.Static water level below top of casing: 12 ° (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use '+" 1617 Mail Service Center,Raleigh,NC 27699-1617
1
11.Borehole diameter: L a (in.) 24b.For Infection 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: (}t,}N.l l construction to the following:
(ie.auger,rotary,cable,direct push,etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 60 Method of test a ).Q.-' (r et 24c.For Water Supply&Infection Wells: In addition to sending the form to
1 the addt>ss(es) above, also submit one copy of-this form within 30 days of
13b.Disinfection type� i Amount: a Cif e completion of well construction to the county health department of the county
J where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water ResourcesI Revised 2-22-2016