GW1--06525_Well Construction - GW1_20241101

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
'VO �a 1 1l/ itte . 14 WrlTE2 ZONES
Well Contractor Name FROM TO DESCRIPTION
® H. !>IS 3DiVrtri (
ft.
2-41'3 ft ft.
NC Well Contractor Certification Number 15iOUTER CASING(for mnitr eased wells)OR LINER'(ifap licable)
Gaul_ j 9r{-��T{r,,7 tir Wry 1 E_tft/.__ 4 FR f TO DIAMETER THICKNESS MATERIAL
Company
t.f.t r V V J/ LVJr D [�1 I lj'Uri ft ft. i in. PVC-,
Company Name VVV � �� (!
�'� �/�� pp � ��tt�� :16ANINER(',z1SINGOR:11131NG'(geotherivarclosed=loop)
2.Well Construction Permit#:0 *LU2"l —l/I 0 DO FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State.Variance,etc) ft. ft. in.
3.Well Use(check well use): tt: ft. in.
1T:SCREEN ;;
Water Supply Well: ,._. _ . . :.::�, .
Agricultural FROM TO .DIAMETER' 'SLOT SIZE ' THICKNESS MATERIAL
g DReside pal/Public it it. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft, ft. in.
Industrial/Commercial Residential Water Supply(shared) „18.GROUT.,
Irrigation FROM Ti60criTATERIALyilt EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. J ft.
Monitoring ft.ft. ft. ` -.-' ' ,
Injection Well:
ft. ft. NOV I) LU24
al Aquifer Recharge 0Groundwater Remediation
19.SAND/GRAVEL PACIf(if applicable).
(Aquifer Storage and Recovery (Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD „ 4h
Aquifer Test DStormwater Drainage ft. ft. L i' -_1,u, i..}4,;j
Experimental Technology 0 Subsidence Control ft. ft. '
0 Geothermal(Closed Loop) E3Tracer ,2o;DRILLTNGIDG,(roach.additionalsheets fttecessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,„rain size,etc.)
Geothermal(Heating/Cooling Return) (Other(explain under#2l Remarks) 0 ft. lIt ft. 1 ` ,''
4.Date Well(s)Completed:��� 1 l.214 Well ID# Lora ft. L '� ft. icy. , lbw
5a.Well Location: U' ! ft. k�'l ft.
ft. ft.
Facility/Owner one {� 4�®� Facility ID#(if applicable)
ft. ft.
2 ''i (Ir ) V e3f � ' �; river (i(1 1.w`t ft. ft.
Physical Address,City,and Zip f,y �✓f, ft. ft.
��, J11! t l Y r �/ ' 21i REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:35'34 , / Ate, '
8 N a t.2,� I W \ - '1�►e./1
6.Is(are)the well(s) Permanent or E3Temporary signs a of Certified Well Contractor Date
By signing this fonts,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or /M'No with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction 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 welIdetails:
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
cvustn?etion,only 1 G 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: 51' (ft.) 24a, For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100' construction to the following:`
10.Static water level below top of casing: t (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I^ 1(
11.Borehole diameter: i+ci (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
{ . a •above, also submit one copy of this'form within 30 days of completion of well
f
12.Well construction method: t t 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
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13a.Yield(gpm) Method of test:2-Ina Iy'� 24c.For Water Supply&Injection Wells: In addition to sending the form to
t the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type: h14 Amount: ;r,..' � completion of well construction to the county health department of the county
where constructed.
Form CiVAI worth Carolina Department of Enviroaniental Quality-Division of Water Resources Revised 2-22-2016