GW1--06551_Well Construction - GW1_20241101

3 •`tV_IfL.I
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: ,
IV(XVS 'i,�P.eme,
14L?wATERZQNEs .. ...
We1lContractor Nalne FROM TO DESCRIPTION
`� (� 0
ft. ZS]� ft. N)-b pt„v^
/ /1 ft. 6..C�\./ ft. 1 Ai . t/v t
NC Well Contractor Certification Number )
���333 l&;01,11Z1 CASING.(for multi cligiti4e0s)0R 1:INCkili£a cable
ri� tl�,t ` l e Rjai 1 {� _ ,/� , n J
ft.
TO ft. DIAM
ETER THICKNESS MATERIAL
Company Name j'i.flf(�y ti7 IG (l%frl� (f C L �...
�A (�j�V 6ANIST R CASIWOR UBINd eathec►ual ciosed4dop) }
2.Well Construction Permit#:W JEL.2 )2.). V 2� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Cou,tty,State,Variance,etc.) ft. ft. i in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SGREEN r
FROM TO. DIAMETER SLOT SIZE THICKNESS. MATERIAL
°Agricultural • °Municipal/Public ft. . ft. in.
°Geothermal(Heating/Cooling Supply) cResidential Water Supply(single)
ft ft. m
°Industrial/Commercial °Residential Water Supply(shared) 18GRQiJ1. .:.: t,
['Irrigation FROM . TO IATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: • 0 ft. .J� ft. anri r
°Monitoring DRecovery ft. ft. ` 'e Ls A:r ';/ ,L,_j
Injection Well: .
ft. ft. i NOV
DAqvifor Recharge °Gmundviater Remediation t 1 tp 2n
*'}Salinity Barrier 19:SANDIGRAVEGPAGK(tf applicable) -.•
Aquifer Storage and Recovery
y FROM TO MATERIAL 6 EI4I1S,ACEMENT METHOD
Aquifer Test °5tormwater Drainage
ft. ft.
°Experimental Technology °Subsidence Control ft. ft.
°Geothermal(Closed Loop) °Tracer 20 DItILI1NG'LOG.(atiach additlonaUsheets ifnecessiry) .
VI TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
°Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks)
ft. 11
0 ft. PA, L"4.Date Wells)Completed:?/2 c)2 Well ID# 110 ft. 305 ft f,' iiyi't�i
5a:Well Location: ft. ft.
'DMA ct Y�I�Yi ; , ft. ft.
ft. ft. !Facility/OwnerName Facility ID#(if applicable)
4.O8. 6 ISVCU I CXLOCI 0)/ it IG ft. ft.
Physical Address,City,and Zip ft It
County Parcel Identification No.(PIN)
5b.Latitude and longitudein degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
i36•;-,"jS .O N — CL.USS w 71 +�
6.Is(are)the wells) (Permanent or °Temporary
Si tur Certified Well Contractor: Date
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: °Yes or jNo 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 421 remarks section or on the back of this form. I
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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: diSUBMITTAL INSTRUCTIONS
t
9.Total well depth below land surface: (3 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if deerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (.0)t (ft.
Division of Water Resources,Information Processing Unit,
If water level is above casing,use,j"+" 1617 Mail Service;Center,Raleigh,NC 27699-1617
11.Borehole diameter:j4,If, (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: t—t a{t'4 above, also submit one copy of this form within 30 days of completion of well
l��Jl(.[ aconstruction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPP(L�Y WELLS ONLY: 1636 Mail Service,Center,Raleigh,NC 27699-1636
13a.Yield(gpm) I L) Method of test: ,f..- ,L.KS 24c.For Water Supply&Injection Wells: In addition to sending the form to
i �� �- A the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: ifv Amount: .p'iZt. � 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 Resodiees Revised 22 67[