GW1--06549_Well Construction - GW1_20241101

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
ii(O,vl,) 0 rm 1 i4;1VATER`ZONES :.:(
Well Contractor Name FRO11 TO DESCRIPTION
97)S 0
ftft. y�
NC Well Contractor Certification Number
19:OUTER.GASING(frorviulti-cased';wells)OR X;INEIC(ifife Reable). I .
CY� 8� »y�_t,,l.-tt,/ ^ i' I `q FROM TO DIAMETER THICKNESS MATERIAL
Y,�,i2,N if(i F JYU I V LC.�S �X,�A ��fiYY1 p a/U� lV t�- ' ft. �� ft. �,I� D; m. ���
Company Name //'. i�i; rl��Q -14l NNER CASING O1.T(IBING:`(2eeothecmal:'closed400p) .... . ...
2.Well Construction Permit#: c ....ti a dJ p 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: FROM TO DIAMETER SLOT SiZE THICKNESS MATERIAL
Agricultural 0Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Will•csidcntial Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared)
_
Irrigation FR i TO MATERIAL EMPLACEMENT METHOD'fi Al1IOUNT:•-
Non-Water Supply Well: I ft. ft.
!t+'titz Nov € 1 202i
Monitoring DRccovcry ft. ft. r�I J
Injection Well:
ft. ft. ii,.,: K r a• 1 ?,
Aquifer Recharge DGroundwater Remediation r-
,19cSAND/GRAVEL'PACK(if applicable).•;
Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test EtStormwater Drainage ft. ft.
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) 0ITracer 20.DRILLINGLOG(attachadditlonailsheetsifiieeessarv). = r
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO 3RIPTIONSC (color,hardness,soil/rock type,train size,etc.)
ft. CM� ft.4.Date Well(s)Completed: %\,___: Well ID# it. ��—Y�ft. ult��-
ft. ft.
5a.Well Location:
p g �y��,,i�,,, i n,�, ft. ft. I !
(S en u Cd.d.rf lA , 'Ft..n •
ft. ft.
Facility/Owner
fN Name ) ® 1 q Facility ID#(if applicable) ,
( (Ste" on. 11/439f t atui j 151 ft. ft.
Physical Address,City,and Zip t! Ib011-1�2, -7Sj3 i :21;`-REMARKS i. �. �,g p�: ...
County� �1 Parcel Identification No.(PIN) Uir �+- --`utia CI ,►/ 4i, poic
513.Latitude and longitude in degrees/minutes/seconds or decimal degrees: V
(if well field,one lat/long is sufficient) p f ,, 22.Certification: _ �(J F c c-•,S9Ci N ~113i0(1 W �"_ gilt/3 �'1
6.Is(are)the well(s)Etpermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certi/y that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or No with I5A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information aid arplain the nature of the copy ofthis record has been provided to the stall owner.
repair under 4021 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 GW-J 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: (4LO j (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:441— (l-t°. .in (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: Lte I 1 4 (in.) 24b.For Infection 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: 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) 4 Method of test: A 24c.For Water Supply&Iniectil
�i on Wells: In addition to sending the form to
y_ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: ; 0J.Ji+),,,3 completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016