GW1--06533_Well Construction - GW1_20241101

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WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
•
1.Well Contractor
tonttractor Information: '
i'ravis i 1 N e)/ lu 14-WATER ZONES .
..
Well Contractor Name FROM TO DESCRIPTION
rt. IUD
rt. r Contractor Certification Number ®ft- �i�.ti re. iv1 f?tt3 lotZj p/ i_ ;15a`.OUTERCASING(formells)ORLILNE{1R'(ifap`bcabable)G.'i(�J; 'Y3'I
NC Well per/ f j/� (( ,^ /"el I t e, V, 64)-1-pats ikeLt q Pimp I p 1V i I d e • F FROM
ft TO ft. D (�r ji,R in. THICKNESRic_,
MATERIAL Company Name Y 7 V
i / 7 r I I —7(-7-1 3 1 PROMNERCASWGORTUHIAMET othermal:clICK loop). = , .,.
2.Well Construction Permit#: 11f. li 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): ft. ft. in.
Water Supply Well: 17.'SCREEN.: :'
.FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
Industrial/Commercial Residential Water Supply(shared)
Irrigation FROM TO MATERIAL EmmitcEhMENT METHOD&AMOUNT
Non-Water Supply Well: D ft. 2..1, ft. i ��r b 4�,.t. `i
Monitoring ORecovery ft. ft. _ ` 2
Injection Well: • NO IV L T
ft. ft.
Aquifer Recharge DGroundwater Remediation
19:;SAND/GRAVEL:PAGIC(if applicable) : IV:`Ct1: , ;. ,,;_? r r. 1 f
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD'
Aquifer Test DStormwater Drainage ft. ft. -
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer >20s:eRILIINGLOG:(at tic'hadditlonalat:eettifnecessary)
Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,ete.)
g g Other(explain under#21 Remarks) l 1 ft. ft. �t
4.Date Well(s)Completed: i 16)1 Zy Well ID# •� ft. •5(„5 ft. 1
lt,
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n• ft.Well Location: ft. ft.hyri Flavor
1
Facility! }�cr Name/ (. Facilitytil ID#(if applicable) f� ft. ft.
CaD 1 v� ( marts' fit. iflh?s ft. ft.
Physical Address, it, Zip
4,Li to
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-(SU N --93 C1 a 2 _ w 3- 2:
6.Is(are)the well(s) Permanent or Temporary ignaturc of Certified Well Contractor Date
T By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or tiallo with ISA NCAC 02C.0100 or 15A 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 10 the well owner.
repair under 421 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 9W-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: e SUBMITTAL INSTRUCTIONS
9.Totalwell depth below land surface: i D`� (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:
ic� t
10.Static water level below top of casing: !/ (ft.) Division of Water Resources,Information Processing Unit,
If stater level is above casing,use"+" 1617 Mail Service'Center,Raleigh,NC 27699-1617
11.Borehole diameter: (o I t/(4 (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: 1"v
(i.e.auger,rotary,cable,direct push,etc.) .1 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
13a.Yield(gpm) 1,3() Method of test:2_1�1'c ,(i,S 24c.For Water Supply&Injection Wells: In addition to sending the form to
r •�"�' r} the address(es) above, also submit one copy of this form within 30 days of
'F)13b.Disinfection type: ' Amount:(.01 ,/ 5 completion of well construction Ito'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