GW1-2022-10283_Well Construction - GW1_20221114

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WELL CONSTRUCTION RECO GW-1 For Internal Use Only:
1.Well Contracton.Information: i
• S ' ` .14.WATER ZONES 1 j
Well Contractor Name FROM TO DESCRDTITON
3 S 3 S 6 fe ODft 1
ft ft
NC Well Contractor Certification N Cr
�-/�/ 15.OUTER CASING for multi-Eased wells OR LINER if a 4cable
Y �lJ"Y»Q/!�I C + FROM TO DIAMETER I THICIOVESS MArE[tIAL
Company Name ft ft in
3 7LI 5 /3 16.INNER CAS_OR TUBING eot6ermal closed-too
2.Well Construction Permit#: CJ ...J/ FRO I TO 1 DIAMETER TIIICKNM MATERIAL,
List all applicable well construction permits(i e-EuC,County,State,Variance,eta) ft ft' 51 in
74 f�L
3.Well Use(check well use): ft fL in.
Water Supply Well: 7.SCREEN
❑A cultural FROM TO DIAMETER SLOT SIZE TffiCIOVESS MATERIAL
� ❑Mtulicipal/Public ft ft
❑Geothermal(Heating/Cooling Supply) idential Water Supply(single)
01nd»strial/Commercial idential•Water Supply(shared) ft ft I .
18.GROUT
❑lrri tion ❑Wells>100000GPD FROM To MA f EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: g
rInjection
toring ❑Recoveryt. ft e
Well: --
fer Recharge ❑GroundwaterRemediationft ftfer Storage and Recovery ❑SalinityBalrier 19.SAND/GRAVELPA ofa liableFROM TO MATERIAL IMLACEMENTMETHOD
er Test ❑Stormwater Drainage ft ftimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other lain under#21 Remarks) FROM I To i DESCREMON color hardness.soilirock in sim,eta
ft ft
4.Date Well(s)Completed: . .3� ZZ Well ID# ft k
Sa.—Weelll Location: ft ft
ft &
Facility/Owner Name Facility M#(if applicable) ft R V A
176 PI r Va�� �Zd ��/Innr� ..ft ft
Physical Address,City,and Zip ft. ft
21.REMARKS.(
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certifrc tioII:
31. ' 31 ' .3"__N, 96 ' G • 59 W '�
7- ZZ
6.Is(are)the well(s): ❑Permanent or ❑Temporary 1930 IF Signature o Ceutified Weil Contractor Date
By signing thisform,I hereby certo that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Otto 15ANCAC 01C:0100 or'2SANCAC 02C.0200 Well Construction Standordr and that a copy
If this Is a repair fill out Imam well construction information and explain the nature of the of this record has beenprovided to the well owner.
repair under#21 remark section or on the bath of th►sform.
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 construction info
construction,only I GW 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
^� r 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: orf� (fti)
For multiple wells list all ijdlfferent(example-3Q200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 61 d (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing use"+ �0 Llformation Processing Unit,16171MSC,Raleigh,NC 27699-1617
11.Borehole diameter: G (in,) 24b.For Infection Wells:Copy t1 DWR,Underground Injection Control(1UC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction restmethod: r��"��y,, �- 24c.For Water SUDDJy aad ODea-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,dyed push,etc.) county envrronmental health department Of the county where installed
FOR WATER SUPPLY WELLS ONLY:
/� " 24d.For Water Wells Droducing'over 100 000 GPD•Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: y�.y�� Permrt Progrnm,1611 MSC,Raleigh NC 27699-1611
_ IS
13b.Disinfection type: Amount 6-ft—
Form GW-I North Carolina Department of Eavironmental Quality-Division of Water Resources
. Revised 6-&2018