GW1--06375_Well Construction - GW1_20241025

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
1.Weil Contractor Information:
''fig pr,jdott- `21(6.ee16, 14.WATER ZONES. I i
WelObntractorName FROM TO DESCRIPTION
,A ti? (D. -.4 ace ft. ?2a ft. C,/,"
NC Well Contractor Certification Number
ff 1I 11//JJ�� /} (`,St �p/� 15.OUTER CASING(for mull ed welts)ORLINER IlIappl cable) =:a:.-
Y ;'rS VVC( /Zd /� 9 ULC Il L�� FROM To- DIAMETER çcKNEss MATERIAL,
Co Name ft. 76 ft. C':gym. R a1 -pre,
i' id(,/� ° V J 16:INNER'CASING OR.TUBING(geottieeral ciosed4oup)�.
2.Well Construction Permit##:/ rIJ ` FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well conshvctfoh permiurae.UIC,County.State.Variance.etc.) ft. ft, In.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN> _
f FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. p: ' In.
Geothermal(Heating/Cooling Supply) Mt idential Water Supply(single) R. R. ' in.
Industrial/Commercial °Residential Water Supply(shared) _
18:GROUT -. '- ,. -.....-
Irrigation FROM To MATERIAL EMPLACEMENT METHOD&AMOUNT
Non Water Supply Well:
Monitoring DRecovcry - ft. 1G
Injection Well: _. _
Aquifer Recharge DGroundwaterRemediation ft ft.
•
•e
:19.SAND/GRAVEL PACK(if applicable) : .
Aquifer Storage and Recovery EISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage R. ft-
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer :20 DRILLING1A)G:(attach additional sheets If necessary) •. •-
FROM ro DFSCRIPTtoN(
- Geothermal(Heating/Cooling Return) Other(explain under#21 Rematks) (color,hardness,wmroek type.saw s�etc.)
_ 0 ft. CO ft' X..td Clap
4.Date Well(s)Completed:,(Y o(2 2 y Well ID# G ft 20 G' irt7
5a.Well Location: 71, ft' 07a n' G' /'1
7'I/8,rfa,a/ • ft. ft. ' - ' '
Facility/Owner Name Facility ID#(if applicable) ft. it
5.3 ye &iv/1/0 dr Liflev/h7teNa Fc30 ft. ft. OCT 2 L• Z024
Physical Address,City,and Zip ]f 1:. rr-.-;:.: '..arc'e y?02 1.,PA
L.Act/M . 3 93 - 21.REMARKS C.` a.'s'2'e}
County - Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �ee�� ll� -n
(if well field,one lat/long is sufficient) 22.Certification: Q.Ldi�,a -A
s:?t;.i/co N Fi P Y7ffa w ,,�,�,�,�er iae 1 .Ae/4/ 6 /rJ a?0 `'
6.Is(are)the wells) Permanent or ()Temporary G d "i7'ofCerti ed wcu Contractor Date
By signing this form,I hereby certffir that the wells)was(were)constructed in accordance
- - 7.Is this a repair to an existing well: Dyes or e r. o with ISA NCAC 02C.0100 ar 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 ofthisform.
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: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd fferent(example-3Qa 200'and 2 1 0') construction to the following:
10.Static water level below top of casing: .5Z2 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing.use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6hI'0' (in) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above,also submit one copyof this form within 30 days of completion of well
12.Well construction method: r CiLN ../ construction to the following:.
(i.e.auger,rotary,cable,direct push,etc.) 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test .?t"t L.(IC(1'- 24c.For Water Supply&Infection Wells: In addition to sending the form to
} ` t the address(es) above, also!submit one copy of This form within 30 days of
13b.Disinfection type�'_'� Amount: 3 cis completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016