GW1--06605_Well Construction - GW1_20241112

WELL CONSTRUCTION RECORD(GW 11 For Internal Use Only:
1.W 1 Contractor Informatlo
i
NI ‘- (11 . (ll.'Q =I4 WATER;7ANE3 c,, i.:i _ a _v
Well Contractor Name
Ertl FROM TO DESCRIPTION
t, - ft. rt. 11, I(�
NC Well Contractor Certification Number ��Oft- ��(5 tt. 1/Z
":15OUTER:CASING:(for_multi-caseit.Wells)-01CT:tNER(ifen licable)4: „
FROM TO - - DIAMETER' THICKNESS MATERIAL
!� J�—.k ft. t ,3 ft. Gv 1/ , ', in. `:/J(L`a t P vc
Company Name
t• / � �(/ll� -=36ANNER CASING ORiTUBING=(aeotheriiinitloseddtiop)``=
2.Well Construction Permit#:" 1 l FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,.Count;State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in
Water Supply Well: •17 SCREEN .,$::=. ,u .;
FROM TO DIAMETER SLOT SiZE THICKNESS MATERIAL
,DAgricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
IndustriaVCommercial �IResidential Water Supply(shared) ,a8::GROUT....,r: ,
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. ft. o,,,�;N)td-. . p(lht_
Monitoring - - DRecovcry- ft. ft. f -
Injection Well:
it. ft. _
Aquifer Recharge (iioundwater Remediation
19 SAND/GRAVEL'PACK`(if applicable)_r
-
Aquifer Storage and Recovery Salinity Barrier FROM TO- MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology DSubsidence,Control ft. . ft.
Geothermal(Closed'Loop) 'Tracer 10'DRIILLING%LOG(attaoh`additionai'sheets"':If necessa0) _..
Geothermal(Heating/Cooling Return) QlOther.(explain under#21 Remarks)3 FROM ft. To ft. DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
cocii
4.Date Well(s)Completed:lt— CO' T WellII)# '1O f1• WI) ft. Glue c fj_y;4—a-
5a.Well Location: ft. ft.
Facility/Owner Name / Facility ID#(if applicable) ft. ft.
6649 Cyr I( g 0)6, . MC alc(6 ft. ft: NOV i 2 2O24
Physical Address,City and Zip ft. ft I r fo A` ,
GILA g 'qq(e tet v�t�0SOO 1 / (( 9 9 i21 REiVIARKS .it .1l , .:... .C. tir.lik „ Y_..
County ( '-1 'E —Y05 2lp AA
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:
3C. - 3`3 "I nn °�G I g N 0 - �P 3 W- a W 3AUicU4fL
I 2
6.Is(are)the well(s) Permanent or Temporary Signature of CertifiedWell Contractor Date
By signing this form,I-hereby certify that the well(s)was(were)constructed in accordance
7.Is.tl»s.a repair to:an-existing well:. fixes or ril No - with I5A NCAC 02C.0100 or75A 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#21 remarkw.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 useahe 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: f SU BMITTAL•INSTRUCTIONS
9.Total well depth below land-surface: " `i (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: J
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50
10.Static water level below top of casing: (ft.) Division of Water Resources,.Information Processing Unit,
If water level Is above casing,use"+" 1617 Mail Service Clatter,Raleigh,NC 27699-1617
•11.Borehole diameter: (0 (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:a_.(� construction to the following: :
(i.e.auger.-rotary,cable,direct push etc,) "
I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY LS ONLY:. 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield,(gpm) Method.of test: - 1 t(1 24c.For Water Supply&Iniecton Wells: In.addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: .1-leT (I Amount: t I b, 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 EnvironmentaLQuality-Division of Water Resources' Revised 2-22-2016