GW1--06648_Well Construction - GW1_20241112

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L' ELL CONSTRUCTION RECORD`(GW-1) For Internal Use Only:
1.Well Contractor Information:
I
(n D J 96!) 14 WATER'ZONES 1. I ..o ...
Well Contractor Name FROM TO DESCRIPTION
DESCRIPTION
2413 0 ft. i?J ft. ,2/cOM
'� 1/ ft, ft, j�
NC Well Contractor Certification Number I
1. < �//�1�9 {d!`71 l e ip�[1 +1 IeI//(0/� �il d,A N��/!/ 15i OUTER CASING(for'riwih-cased`•veils)ORLINER fir ap'liable)
�I W �_ J✓(j/1 Y� J M I 1 " b°t j p /t`�° i" "�J• FROM ft.
�® ft.
D�t l R in. THICKNESS MATERIAL
. .. ..
Company Name ✓t v J 0 1
.I6JNNE&CASING:OR'TUBING(geothermal closed4tiop).
2.Well Construction Permit#:0 SS .+ Z ' FROM 'TO DIAMETER THICKNESS MATERIAL •
List all applicable well construction permits(i.e.UIC,Caa,gt State,Variance,etc.) ft. ft. ' in.
3.Well Use(check well use): ft. It. , in.
i
Water Suppiy Well: 17 St7I2EEN
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.; ,
Geothermal(Heating/Cooling Supply) gal Residential Water Supply(single) ft. ft. in.'I
industrial/Commercial DIResidential Water Supply(shared) '
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: C) ft. / ft. I
Monitoring 0Recovery es ft. ft.
Injection Well:
Aquifer Recharge ft. ft.
9 g DGroundwater Remediation
Aquifer Storage and Recovery [�Salmi Barrier 19:.SAND/GRAVEL PACK(if applicable). -
E ty FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) 0 Tracer :•20:DRILLING:LOG(attaet:additlonal<sheets iftnieessary).(
Geothermal(Heating/Cooling Return) F11,9111
ROM TO DESCRIPTION(color,hardness,soil/rock type,
(H g/ g Other(explain under#21 Remarks) a claim size etc.)
0 ft. 50 ft. /b )s 1 r�i �.
�,�y �( t11.J t..�tti9t`.t.,B,I L._.�:��_^i `�FT. `: :i
4.Date Well(s)Completed:q ( ZLI Well ID# SO ft. ��ft. �jIig'(, is t ,....,.,, a.:; i., .__,
Sa.Well Location: ft. it. Q U 1 2024
tp ,) !dl�l_ y ac, ft. ft. .. r -, -
Facility/Ow et-Name Facility ID#(if ft. tE,:�;rr :•:..-.- ..,
e rp (,J (i applicable)
ft. } ;, fi
��" J Nio t1ld�e - f�(i�k !!e, d cq ft. ft. NU �'' 8 �U24
Physical Address, ity,and Zip ft. ft.
21`�REMARKS -,.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification:
6I
33.•3Lfg N - 8Z I [ w :' t '-�°e- ® 20
2-471
6.Is(are)the well(s))!!Permanent or OTempor ary Signature of Certified Wet on Date
By signing this form,I hereby cert(that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or r No with 15A 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 avian:the nature oldie copy of this retard has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
( drilled: 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (0 5 (ft.)
For multiple wells list all depths if-different(example-3C7a 200'and 2@100') 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing: 90 (ft.) Division of Water Resources,Information Processing Unit,trimmer level is above easing,use"+"
f 114
fr i 1617 Mail Service Center,iRaleigh,NC 27699-1617
11.Borehole diameter: (0 r°"!�y�j (in.) 24b.For infection Wells: In addition)to sending the form to the address in 24a
12.Well construction method: I'�(J( above, also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) 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) J Method of test: Rr 1Q�1AA S 24c.For Water Supply&Injection Wells: In addition to sending the form to
,�—� „ the address(es) above, also submit one copy of this form within 30 days of
13h.Disinfection type: Amount: 5. completion of well construction to the county health department of the county
where constructed,
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-201 G