GW1--06544_Well Construction - GW1_20241101

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: . �
1.Well Contractor Information:
lt.' ri K R it Y 44.WATER ZONES ._. _:.;` .
FROM TO DESCRIPTION
Well Contractor Name u �/ r��
44 t lD ft. ft. Lr t Y?'1
NC Well Contractor Certification Number - i'
el\re&tit,_
15:01ITElf CASING(for multi-eased:wells)ORLINER'(if ni'lietible) '
�J-,_ ( ,�? �.,�,iFROM TOf DIAMETER THICKNESS MATERIAL
1 E/Iieys 1A&U Pump i W 1 . 0 ft. H O ft. (�(! to PVC
Company Name (( �,,�p � ;36 iNNERCASINGAR'-TUB{Y(NG`(geothermal c]osed=loop) J Wr
2.Well Construction Permit#: _ 5 V OgtJ/VV 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., :t .., ,.;q
"
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft, in.
Geothermal(Heating/Cooling Supply) 01Rcsidential Water Supply(single) ft. ft. in.
Industrial/Commercial 7z residential Water Supply(shared) 18:GROUT.
7. Irrigation FROM TO MATERIAL EMPLACEMENT.METHOD&AMOUNT
Non-Water Supply Well: • rt. ZO it. �TI[' l�� " '`�- 4.'1.:r %..' r... „
Monitoring Recovery ft. tt, fn i i t�Ir►
•
Injection Well: ft. ft. rJo V +i 1 %0`d
Aquifer Recharge DGroundwater Remcdiation it
19 SAND/GRAVEL PACK(if'applicable) -.%' t i r• t,
Aquifer Storage and Recovery OlSalinity Banter FROM TO ' MATERIAL EMPI ACEi TENT METHOD '
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
,i..
�.. Geothermal(Closed Loop) Tracer .20;DRILLENG LOG attach additional sbeetsif:necessary) . ;;
Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FRRI TO DESCRIPTION(color,hardness.soiltrock type.grain size,etc.)
�j q ft. I10 ft. N
4.Date Well(s)Completed: q)2_(fiizq Well ID# I10 ft. i'3OSft. r ,:L„�Sa.//�jWell Location:
�' tt. ft. ���///ttt l lf�
•
Lax Fuscf��r�i ft. ft. '
Facility/Owi rName Facility ID#(if applicable) ft. ft.
1S31 .J � + c 1ri i Vou jas(✓i-(1. .,`ig1s, ft. fft.
Physical Address,City,and Zip
a
r
Li '.1UO-E 2,—I2A; '2111fEMARKs
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:
3S.Lo B N -'g3 D f t w l d.
6.Is(are)the well(s) Permanent or Temporary Sibtiamre of Certified Well Contractor Da c
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: EYes or No 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 to the well owner.
repair under 121 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 I GWj I is needed. Indicate TOTAL.NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS'
C7— i
9.Total well depth below land surface: t i 7 (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 a 100') construction to the following: f
10.Static water level below top of casing: r (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: tO)J<.P (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12 above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: A.-kJ 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
13a.Yield(gpm) .2_s Method of test: 21/14,j4,.ki'c 24c.For Water Supply&Infection Wells: In addition to sending the form to
�' the address(es) above, also submit j one copy of this form within 30 days of
13b.Disinfection type':.: ' -Amount ) completion of well construction to the county health'department of the county
where constructed.
Form GW-1 North Carolina Deppttirtein of Environmental Quality-Division of Water Resources Revised 2-22-2016