_Well Construction - GW1_20230310 (4)

WELL CONSTRUCTION RECORD(G'W-1) For Internal use Only:
Ljj��Well Contractor Information:
,� g l Q �! ��n
_.4�A''si � 1 j ,t�tl v'�t'z— d, J `JWV°�-f 2"r`a"A 14.WATER ZONES
FROM TO DESCRIPTION
Well ContractorName
D' r- � D'
NCWellCoatractorCectificationNumber 16.OUfERCASING formultiensedP+ells ORLII�iIIi da cable
FROM TO D1AMErEIt 'THICK111FS8I MATERIAL
ft: ft in- I I J
CompanyNamc
-�.� 16.1NNER CASING OR TUBING eothermal dosed-lao
2-Well Construction Permit#: G o, -, ,, FROM To DrAHWTER THICKPIEss MATERK"
9 !/
List all applicable well constructionpermits r.e.WC,County Stale Yariarice etcJ?f r F_ �.Y 74
n' I�6 t� �(j2[ d/L,; �'�
3.Well Use(check well use): MAP, /� il. ��
Water Supply Well: FROSMCREZ TO DL4NLrn R SLOT srce THIC81VFS3 1lrATERIAL
❑Agricultural ❑Murn0pal/Ptiblic?:', _ .) ' /L(vtL ��S.�fr. T I( 1O 76 .64
❑Geothermal(lieatiug/Cooling Supply) ❑Residential Water$iipply{single) % & in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
off tlon ❑Wells>100,000GPD FROM To MATMAL EMPLACIItMUNEMOD&AMOUNT
Non-Water Supply Well:
❑Monitoring ❑Recovery it fL
Injection Well: IL fL
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a cable
❑Aquifer Storage and Recovery oSalinity Barrier FROM TO MATERIAL EMPLACMENT M MOD
❑Aquifer Test ❑Stormwater Drainage Z/ M S fL
❑Experimental Technology ❑Subsidence Control fL fL
❑Geothermal(Closed Loop) ❑Tracer 20.DRII.LING LOG attach additional sheets Irriecestsa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM f TO DESCRIPTTOx cotor,hardness,souftek type,gain she,etr
4.Date Well(s)Completed: �' Wcll LD# M 5/HIE, 64
Sa.Well Location:
IL
xe
Fa�cili�ty/OwnerName
/
�1�eutL�. it
Physical Address, M
6)C5()C:R VTy Z 2L REMARKS
County ParcelIdeotificationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(f well field,one tat/long is sufficient) 22.Ce cation: ,
fij
6.Is(are)the well(s): moment or ❑Temporary Signature of C " ed ell Contractor Dare
Bysigning thisform,I hereby cerfify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 8? I SA NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature ofthe ofthls record has been provided to the well owner..
repair under921 remarks section or on the back ofthisform.
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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
r
9.Total well depth below land surface- (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3Q200'and 2@100)
of casing: 24a:For All Wells: Original form to Division of Water Resources (DWR),
30.Static water level below top g- / ,y (ft') Information Processing Unit 1617'MSC,Raleigh,NC 27699-1617
Ifwaler level is above casing use
d+3"
11.Borehole diameter. l (jn.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: u� � � 24c-For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.anger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Lr2ducing over 100.000 GPD:Copy to DWR,CCPCUA
Pernut Progmat,1611 MSC,Raleigh, C 2T6 9-1611
13a.Yield(gpm) Method of test ® t
13b.Disinfection type: fl'G�/� � Amount:
Form GW 1 North Carolina Department of Envuonm®tal Quality-Division of Water Resources Revised 6-6-2018