GW1-2023-01627_Well Construction - GW1_20230214

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
J 1 1 p�G'+V Q,. t I4.WATER ZONES `
Well Contractor Name FROM t TO DESCRIPTION
Ai Ft r ,c ft. � 0 o it. w,
. � P
C�1 fL (,(0 ft.
NC Well Contractor Certificate n Nw er D'`'' 1 e�" V - rn
R t 1 I r �. t IS.OUTER CASING(for multi-cas will§),Olt LINER([EepP4eabk?
' ' _ m �r FROM TO DL%,*IETER THICKNESS MATERIAL
1ah V001k ft. 3 ft. in. v c,
Company Name—�—
I' 7 G {16:<INIYER CASING OR T ING eottisrata)ilosed-loo
'w 2.Well Construction Permit#: G J P DZ Z FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits fl.e.VIC.County,State, Variance,etc.) R. ft. In.
3.Well Use(check well use): ft. tt. in.
LOAgricultuml
Well: "I7i:SCREE}Y
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑1VjunicipaUPublic R. ft. 1n•
eating/Cooling Supply) i11�1esidentiai Water Supply(single) f f in•
mmercial ❑Residential Water Supply(shared) iB:GROUT
❑Wells>100.000 GPD FROM TO MATEEK I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O it. ),I it. h
❑Monitoring ❑Recovery ft. ft.
Injection Well:
R. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19nSAtVl)iGRAVEL'YACIC if,a' IIcabte
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage n- fL
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 2Q:DRILLINGLOG'attachaddittoualshe--ifnecesa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soft/rock type,grain size,etc.
it. S ID rt. G 1*-
4.Date Well(s)Completed: 2 7-ZL Well ID# !s 0 ft- 1)
5a.Well Location: ft. f<.
I t I A •) fr ft,
STQIP 1neh J 0 IT G
Facility/Own r Name Facility ID#(if applicable)
`75fl S- Tamif lew j LJCJ ft. ft.
Physical Address,City,and Zip'-' R' ft.
p IC e D 1 v G b 9 21.REMARK-g
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(!f Wcii uciu,vuc eau rues is�uiricicul 1L.Lerrllica Don'
N W -z,T- zz
6.Is(are)the well(s): tpermanent or ❑TemporarKNo
Signature of rti,ed Well Con ctor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: []Yes or 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner,
repair under#21 remarks section or on the back ojthis form.
23.Site diagram or additional well details:
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: i 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: A) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dii ferent(example-3@200'and 2@100')
10.Static water level below top of casing: 2.0 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ijwater level is above casing,use"+"
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: Copy to DWR Underground Injection Control(IUC)
Program,1636 MSC;Raleigh..NC 27699-1636
12.Well construction method: r ra k�� 24c.For Water Supply and Open-Loop Geothermal Return Wells.Copy to the
(i.e.auger,rotary,cable,direct push,etc.) I county environmental health department of the county where install
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
b',"�( Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) I)- Method of test:
13b.Disinfection type: -1n t Amount: ' 1
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018