GW1-2023-01628_Well Construction - GW1_20230214

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only.
1.Well Contractor Informttion:
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FROM TO I DESCRIPTION
well Contractor Name A ft. t7fL
o A ft. fL
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ft. ft in. PVC,
Company Name S(//�J
2.Well Construction Permit#: W L uG FROM To DUMErBR TtttcxNEss MATERIAL_
List all applicable well construction permits(Le.UIC,County,State, Varliitiee,etc.) ft. ft. In.
3.Well Use(check well use): ft. ft. in.
Water.$upply WeH:
FROM TO DIAMETER 9LOT SIZE TM I MATERIAL
aCieotbermai(rieattnglt oming supply) dKesidentiai water hupply(single) i ft. ft. In
Ellndustrial/Commercial ❑Residential Water Supply(shared)
01triization DWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD tt AMOUNT
Non-Water Supply Well: 4 ft 20 ft 0 S
Monitoring ,Recovery ft, ft. I
Injection Well: IL ft.
OAquifer Recharge ❑Groundwater Remediation
" 9 V1tI PA- 1[cilir 777777
• L]Agntter Test ❑StoimwaterD amage
OExperimental Technology OSubsidence Control ft. fa
❑Geothermal(Closed Loop) ❑Tracer :1drlt1ilLLil+Itrl; attaehddtttiin "fsiStiec : .. a? a "
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardnen,soillrock n SIZA,eea
Q ft- 3oft. ct r
4.Date Well(s)Completed: Well mo 11..yy��p ft• ft. L
Sa.Well Location: ,
t�rcda 10thib n ft I ft.
Facility/Owner Name Facility ID#(if applicable) ft. 1t
S935G fL ft.
Zip ft
Physical A City, fL
oh00'au121gt 7 7s
rCyounty Parcel Identification No.(PIN)
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6.Is(are)the well(s): 4ermanent or DTemporary Signature o ertified well Contractor Date (/
By signing this form,l hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: Dyes or o ISA NCAC 02C.0100 or ISA NCAC O1C.0200 Well Construction Standards and that a copy
r1his is a repair,fill out knotwr well construction information and explain the nature of the of this record has been provided to the we/l.owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
9.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same 11°"lay Ubc ULU ud"V,uua lydgl:w prtrvluc aitiiuurrdl wwt cuwiuut 1%YU u>f0
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (ADU.icz V VGA Alt INWl "LV..J.I Vu slay awu ailil u duuaua/uac yar,w::,.. .d,,..s.
dulled: 1 24.SUBMITTAL INSTRUCTIONS
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 if di1(ereni(example-3@200'and 1®1000
10.Static water level below top of casing: Za (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
lfwater level it above casing,use"+r Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
24b.For Infection Wells: Copy to DWI;,Underground Injection Control(IUC)
grogram, 10�30 ivintr,xateign,ivt-..4royy-rozo
12.Well construction method: a 24c.For Water Su 1 and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100 000 NJ Copy to DWI;,CCPCUA
13a.Yield(gpm) Method of test:
Permit Program,161 MSG,Raleigh, C 27 . 61
1
13b.Disinfection type: T h Amount: i Z
Form GW.i North carntina Denariment of t nvtmnmentai Unaury_urvtalnn nt water Hexnvrces t2eviaen n-h-1111 n