GW1--06669_Well Construction - GW1_20241108

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:tio •
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1 Ot I✓!S (1 r �.1! l
.p t. 4:WATEB`7.ONES:.:;
Well ContraetorName FROM TO DESCRIPTION
42-3g 0 ft ggs ft. - owt
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING;(for:multi-casedWills)OR LINER Of lieshle),.
r FROM ft. TO D ft. DIA{M in.ETER THICKNESS MATERIAL
Company Name
PVC
C
� I .16.INNER'CASING.ORTUBING.(geothermal.closed-blip).'
2.Well Construction Permit# 1
: /� A.) FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.:SCREEN
FROM TO DIAMETER SLOT elm' THICKNESS MATERIAL
DAgticultural DMunicipal/Public ft. ft in. -
DGeothermal(Heating/Cooling Supply) KiResidential Water Supply(single)
industrial/CommercialResidential Water Supply(shared) ft. ft. in.i
18..GROUT"..
flitrigation FROM • TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 tt •
20 ft. p !t �,,�
Monitoring
Reeovery ft ft �iU
Injection Well:
Aquifer Rechargefr• ft.
q0GmundwaterRemediation
Aquifer Storage and Recovery Salini Barrier l9.SAND/GRA VELP.ACK(If applicable).
_ � ty FROM TO MATF.RIAi. EMPLACEMENT METHOD
Aquifer Test Q}Stonnwater Drainage ft. ft.
Experimental Technology Subsidence Control it. ft.
Geothermal(Closed Loop) Tracer 20..DRIL LING LOGi(trttacij dditional sheetsaf necessa.ty).
Geothermal(Heating/Cooling Return) f. Other(explain under#21 Remarks) ' FROM To DES�RIPT1ON(color,hardness.soil/rock type.grain size,etc.)
1 t i - ft. 1)� ft. 0 9
4.Date Well(s)Completed: 101141 N Well UM ( 1V tr�1 .�
"� ft. � ft. (�� 11..Y"
DI t
5a.Well a f i ft. ft. ( _
'l U6 vie -61 l ft. ft. N.ham, •,,...,R. ' ii ii .
Facility/OwneerrNaamnc 1 j �)�FacilityID1#(ifapplicablee) (j� n ft. ft. • NOV !Z ,Q
Co?g L✓1 C.S Cli i✓K l�'..t jya4j,
?TAU ft. ft. i V L� ,
Physical Address,City,and Zip ft. ft.
County t., Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) `` tt'' 22.Certification:
W I rS J
Signature
Ce Certifiedtee J���
6.Is(are)the well(s) Permanent or Temporary g Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or 2iNo with ISA NCAC 02C.0100 or ISA 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 remarks section or on the back of thisform.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,or 1y 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
y� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 50"5 (ft•) 24a. For All Wells: Submit this'form within 30 days of coo 1
For multiple wells list all depths if different(example-3@200'and 2@I00') construction to the following: y p eti0n of well
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10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
ii water revel is above easing,use"i(( 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: LO 14 (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: !1 1 construction to the following: i
(i.e.auger,rotary,cable,direct push,etc.)
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Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 2- ,�.�'� 24e For Water Supply&Iniecti on;Wells: In addition to sending the form to
I .� �i ..� �^ the address(es) above, also submit one copy of this form within 30 days of
113b.Disinfectieretype: 11 1 1") Amount: "l 1` �.S .lcompletion.of.well.constrtiction.tol lhe..county.Jwaltlydepartmentofthe.county
where constructed.
Form GW-! North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016