GW1--06668_Well Construction - GW1_20241108

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WELL CONSTRUCTION RECORD(GW-1) • For Internal Use Only:
1.Well Contractor Information:
1
w AA)WO-
Well Contractor Name FROM TO DESCRIPTION
rt. Sft. 119 'Y]t.j 0
ft. 94 i S ft. i ,�
NC Well Contractor Certification Number 1� ...
/' 15:'OUTER CASING•04 intdtr caseit• OWLINER'W.a-p ble):
by-ant t?J4-1'tc�A/� J pD 4- 'a ` i i Ti i -. FROM TO D[A111ETER THICKNESS MATERIAL
Company Name
ii"JJIy tt)J!hLf/C i' YlJ iJlf r 1 !/� ft. 33 f6 yt 1t j_ m. �(`tC,
1/��r y�� { .16sl':JINNERCASING OR TUBING((geothermal closed loop) tip '�. ` ..
2.Well Construction Permit#: `� ltrt �•�{I FROM TO DIAMETER THICKNESS MATERIAL,
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FRO SCREEN
o DIAMETER
Agricultural Municl al/Public SLOT SIZE THICKNESS MATERIAL .
P ft. Ct. iu.'
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared)
18'GROUT f
Irrigation F OM TO IATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ff p'� ft. {t k irti-✓ra h
Monitoring :Recovery ft. f�C� ft. •
Injection Well: ft. ft.
Aquifer Recharge 0 Groundwater Remediation
Aquifer Storage and Recovery (''lSalini Barrier -,19 SAND/GRAV.EI:-PACK(If applicable).. _ . ..
try ty FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. . ft.
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) QTracer :20cDRLLLINGtLOG(attachadditiut,alshettitifnecessary) ..;
Geothermal'(Heating/Cooling Return) •Other(explain under#21 Remarks)• FROM TO DESCRIPTION(rotor,hardness,soil/rock(mile,grain size,etc.)
.-�1 •
U II. 33 ft. !t j/5�
4.Date Well(s)Completed:0 i 2 4 Well ID# 33 ft' SUS ft. l t1jL'" {'/
5a:Well Location: ft. ft.
ft: ft. '
Facility/Owner Nitrite i Facility ID.I(if applicable) ft. ft.
rt'It f { , e NOV
10- �i 6 Sl�(�i� Liti) �. di•t .� , S11ie? Y ft. fr. 0 8 2024
Physical Address,City,andZip �� ft. ft. .. ! a.
1� .. Al 1 ...
..'fiii'.rr.I{I��r-- C .21 .1tEA1ARTCS' ,,. 1'; r�.,y
v c'' T767 :gip 7 Zct
County 9 Parcel Idetitifiratton 1n.(PI'IN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:.
S. (oZ� N --Sv,0514 W j( 'r
6.Is(are)the wells Permanent or Te ry
OTa Signature of Certified\ elV i C untradlor j Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ,DYes or ONo 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 explain the nature of the copy of this record has been provided'to the well owner.
repair under#121 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: p SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ( >i[lr, (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: i
10.Static water level below top of casing: f°' (ft.) Division of Water Resaurees,Informatian Processing Unit,.
it water level is aoore easing.use••-r 1617 Mail Service i enter,Raleigh,NC 27699-1617
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11.Borehole diameter: A.S./ I�•' (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.) a.
Division of Water Resourees,dUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Z/ CAsending 3 d�!(1 (,�� 24c.For Water Supply.&Injection Wells: In addition to the form to
the address(es) above, also submit one copy of this form within 30 days of
113b.Disinfection t3pe:_ -. f l "i _ Amount: 103 � completion of well construction to Ithe county health.department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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