GW1-2023-01745_Well Construction - GW1_20230213

WELL CONSTRUCTION RECORD GW-1 For Intemai Use Only: —_
1.Well Contractor Information: T
14.WATER ZONES
FROM DFSCRIPTIFROM TO
Well ContracwrNamo /, rt. -
`i
_31s7- ltn
NC Well Contractor Certification Number IS.OUTER CASING for multicas A wells OR LINER f a licable
:J FROM t E4��TSA THICtC.'FSS ` l�UCnWell *- I (J f 7� / ` in. LAO
Company Name (�^ 16.INNER CASING OR TUDING geothermal dosed-loop)
2.Well Construction Permit#:Pwsaca/�,` f j U l 1!yCT3 FRO\t TO DIAA1£TER Tf11CK11ESS MATERIAL
� IL In.
C
List all applicable isvll construction permits(Le.UIC ount),State,Variance.eta) —
R, in
3.Well Use(check well use): —
17.SCREEN
Water Supply Well: FROM TO bIAME7FR SLOT SIZE TEQCFQigss MATERIAL
El Agricultural ❑MunicipaUPublic IL ft In. /6 Q
[]Geothermal(Heating/Cooling Supply) Wkegg-fial Water Supply(single) ft. ft. Its.
Dlndustrial/Commercial ❑Residential Water Supply(shared) Ig.GROUT
❑kri •on .[]Wells>100,000 GPD FROM TOqrt�
MATERLtL H+rFLACF.ADL'vTI`SErRon rx a+totrrr
Non-Water Supply WCU: / 6 Qft.
t?•,�,eC V
❑Monitoring DRecovery R- —
InSection-Wel1: it
❑Aquifer Recharge QGroundwater Rernediatioa 19.SAND/GRAVEL PACK if a Iicable
OAquifer Stori&and Recovery ❑Salinity Barrier FROM T'O �tATE:RtnL ).'-MFLACF-NMNr TJMIOD
❑Aquifer Test ` ❑Stormwater Drainage ft -4-- C —+-1� V
D Experimental,Technology ❑Subsidence Control tt ft
❑Geothermal(Closed Loop) ❑Tracer 20,DRILLING LOG attach addiloual sheets If neCSa2W
FROM O sclt1RTIODi color buda call/rocks lad ere
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Relnuics)
Li
4.Date Well Completed: -1(o well ID# ti LA rt � l R VAS
fL ft.
5a.WeR Location: —
ft. R.
-
Facility/OcvnerNaini Facility IDH(ifappticable) -
1 —
Physical Address,City,and Zip n f e —
7 f3C 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one latnong is sufficient) 22.Ce ication:
3
°3S: 714I N 17,1-'51 W .sd--_
� Signature ofC xdficd Well Conanctor Date
6.Is(are)the vvell(s): t�Fermanent or []Temporary
_�.++ 13_v signing thti for r,I L•ereby certifv tl:ar the nrlf(s) as;:ere)constructed io accordance scith
Vf
7.Is this a repglr to an existing well: Dyes or 15A NCAC 02C.0100 or ISA NCAC 02C.0I00 Frei/Construction Standards and that a cop),
Ifthis is a repair, ill out known Well cntutruclion information and explain the nature ofthe of this record has been provided to the well owner.
repair under 1121 remarks section or on the back ofthis farm. 23.Site diagram or additional well details:
8 For GeaprbtrelDpT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction into
construction,only 1 GW_-I is needed. Indicate TOTAL NUMBER of wells
(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 4 _ 24.SUBmITI'AL INSTRUCTIONS
9.T tal well d�ptb below land surface: _ � (ft.) Submit this GW-1 within 30 days of well completion per the following:
For rr�ulNple Fauns list all depths ifdii erent(example-3 aQ200'aid 2Q100�
24a. For All Wells. Original Corm to Division of Water Resources (DWR),
10.Static water level below top of casing: .. (ft-) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-I617
IfWnter level is above casing,use
i 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 6-� (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Qpen-LoopGeothermal Return Wells:Copy to the
(Le.auger,rotary,i cable,direct push,etc.) county environmental heals department of the county where installed
FOR WATTER'SUPPLY WELLS ONLY: 24d.For water Wells p-roducinR over 100,000 GPD: Copy t0_DWR,CCPCUA
} j� �f Pet tart Program 1611 MSC,P al eigb,NC 27699-1611
13i.Yield(gpm) / Method of test:
13b.Disinfection type. Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of WaieT Rcsawces Revised t 6 2018