GW1--06531_Well Construction - GW1_20241101

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: !
1.y4'J `
ellContractorInfoorm�ation:
/I�l.t l/i s E t�-& I I.L s• 14:,WATEIVZO1lE3
Well Contractor Name FROM TO DESCRIPTION {^
tf }}�� ® ft• //) ft. ,� C 8•Z)0i1)r P4
/ 1i�U ft. .dsv'� ft.
NC Well Contractor Certification Number 15 DUTER EASING(forinalti4iiied wells}OR'LINEIt(if-ap `cable}
��y 9 t &n' 1k` ,h'e) A 1 yyl , 'elc_ . FROM ft. TO ft. DIA11[ETERin. THICKNESS MATERIAL
VViCi
Company Name
;�� C erg' .f 16i,DINEAC Till
.
2.Well Construction Permit#: BA---1.3—I,3,l�l�� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County.State,Variance,etc.) ft. ft. in.
3.Well Use(check well use):- ft. ft. in
Water Supply Well: 17kSCREEN :'.
FROM TO DIAMETER SLOT SIZE THICKNESS. MATERIAL
Agricultural 0Municipal/Public ft, iL in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18:GROUT ",_
I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT+
Non-Water Supply Well: • 0 ft. f ft. 1% t' ff '•�
�f t�11 V/t, �4�P,C, � v a r f1I�
Monitoring Recovery ft. ft.
Injection Well: ft. ft. NI •
1 V k) 1 2024
Aquifer Recharge 0 Groundwater Remediation
14:'SAND/GRAVELPACK(if.appfcable) `'. r ri•-, .• ;.. :. . •i,
Aquifer Storage and RecoveryISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD '
Aquifer Test E3Stotmwater Drainage
ft. ft.
ft.
rt
Experimental Technology 0 Subsidence Control ft.
Geothermal(Closed Loop) Tracer 20DRILLIrlGtOG(attaehaddifioiiitliieets'faedessary) _. . ._.
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) f IOther(explain under#21 Remarks)
ft. /�� ft. L{A
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4.Date Well(s)Completed:Ni.-1\E.�-i Well ID# �'-,.'� ft ct I ft. 1 OreDil
i b_J
5a.Well Location:
ft ft,
ft. ft.
Facility/Owner Name f�p 3 Ji�/ r/t Facility ID//(if applicable)
(z ft. ft.
C 11O� V3 s ' d` Vik ,S1!i tit/.f? IIt, ft. ft.
Physical Address,City,and Zip �J ft. ft. •
14ifttra.,-)Ck 103'2I-&1 7L -21 - . .
County i 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: ,
35 001.3 N 03 .633 W
7_..A.---
6.Is(are)the well(s)I i Permanent or JTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certi&that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or )No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out brown well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 4121 remarks section or on the buck 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-I is needed, Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: i
�1� SUBMITTAL INSTRUCTIONS ,
//'" J 9.Total well depth below land surface: SOS (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:
t� �y� I
10.Static water level below top of casing: i_"i (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use '+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 10 1 14 (in.) 24b.For Iniection 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:
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Gj1 2._ I
13a.Yield(gpm) `J V ) Method of test: 9 24c.For Water Supply&Iniection 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: .1�1 An:Mint '1 LBJ completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North•Caivlina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016