GW1--06666_Well Construction - GW1_20241108

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WELL CONSTRUCTION RECORD(GW-1) For Llternal Use Only:
I.Well Contractor Information:
'lfaiiis &V ? 14.WATER ZONES I
Well Contractor Name FROM t 1'U DESCRIPTION
D «. Zb «. U U4pnn
NC Well ContractorCcrrificationNumber
r (� `A'y,, ',/J l5.OUTER CASING(for multi-casedlweW)fIR LINER(if.a DeaNe)
E r i B�/t/ Sy)1 r ►rl/J b� l riW'AMP!
` ' F1 I . FROM TO DIAMETER ' THICKNESS MATERIAL
Company Name (..//V l/Lrir �tf��Vf��L-AJt !!!1 V l f t,J 1 !1 R, Li a 1Y. ►n ILI' 1lo. (�,1V"I'' �U- ��(�116-IINNER CASING OR TURIN (geothermal closed-loop) T v
2.Well Construction Permit#: V L.2 _1-bb FROM TO DIAMETER THICKNESS MATERIAL
List all applicable Irv/icons/ruction permits(i.e.UIC.Counq',State.Variance,etc.) ft. ft. , in,
3.Well Use(check well use): ft. ft. ill.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipaUPublic ft. ft. in
Geothermal(Heating/Cooling Supply) raResidential Water Supply(single) ft. IL in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM 1'O MATERIAL
�y� EMPLACEMENT
METHOD&AMOUNT
Non-Water Supply Well: 0 it.
Liq rt.
07e ;f9'1)YG ftrnt ed
Monitoring DRecovery ft. II ft.
Injection Well:
f• ft.Aquifer Recharge QGrvundwatcr Remediation
Aquifer Storage and Recovery19.SAND/GRAVELPACK Of applicable)
g OSalinity Barrier FROM TO MATF.RIAI. EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control fr. It.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(etteeta addItional sheets If necessary)
Geothermal(Heating/Cooling Return) Other(explain under ii21 Remarks) •
FROM TO DESCRIPTION(color,hardness soiUtack type RhtN Stbq etc.)
/fit 0 ft. L461 ft. /� .l•
4.Date Well®Completed:101'31 1 G.`T Well ID* Lig ft 046 ft. o./1• j-�• ,,, _
"_f� fJl'1/
Sa,.WO
Location:f ` p( y��t� ft. ft. "�' i . ;.a.,.i.,...„;a- ,.i.
;
t �l�1O r 1[) 'hVe 1 f Ir, ft ft.
PSG)V 0
Facility/Owner Name Facility UV(if applicable) ft. ft. ZuL4
.liX""rum Pk but Curt V Y SYr11C LS- KC ft. - ft. r: •:-, -.
Physical Address,City,and Zip ft. it. L' i, ;_r u
WA i WO ? 21.REMARKS
County t'arcclIdentification No.(PTN) Pumped- V4t 1 IKT
4t,/ -1 1l��Ju'� ,t 'aT Ian(
5b.Latitude and logitude in degrees/minutes_/seconds or decimal degrees: ___.-.. ' 1J ��• 1
(if well field,one lat/longis sufficient) 22.Certification:
t35 .G4I N -X'a.o41 W ; 102.1 1 VA
6.Is(are)the well(s)04Permanent or E3Temporary Signa ore ofCeriffled Well Contrectnr I Date
By signing this form,1 hereby certify that the well(s)ricer(were)constructed in accordance
7.Is this a repair to an existing well: [Yes or EtirNo with 15.4 NCAC inc.0100 or 15.4 NCAC 02C.0200 if c11 C.naaMrction Standards and that a
If this is a repair,Jill out known well construction information and explain the nature of the copy of this record has been provided to the well owner. '
repair under 1/21 remarks section or on the back of this firm.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
A.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
chilled: 1 /� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /„45 (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(ty100'and?gloo) construction to the following:
1
10.Static water level below top of casing: jot/�} (ft.) Division of Water Resources,Information Processing Unit,
it writer let el rs atror'e easo,P,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 0 114 (in.) 24b.For Injection 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: ill t,� construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) J
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
/'� !J 1 1636 Mail Service Cent i r,Raleigh,NC 27699-1636
13a.Yield(gpm) �`� Method of test: 2 Y• ,«.s 24c.For Water Supply&Injection Wells: In addition to sending the form to
y}7'(1 Li 3�� the address(es) above, also submit one I copy of this form within 30 days of
i13b.Disinfection type: j j (1 Amount: a5 1 completion of well construction to thil,. county health deponent or the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-201.6