GW1-2023-01818_Well Construction - GW1_20230223

WELL CONSTRUCTION RECO GW-1 For Internal Use Only:
1.Well Contractor.Informat"ion: d
mr{1 14.WATER ZONES _
Well ContraQor Na FROM TO DESCRIPTION
35 3-5oo ft cr�o ft.
NC Well Contractor Certifiw[ion Number ft. ft.
WINNER
G (or multi-cased wells OR LINER rf a Gable
DIAIKETER THICKNESS MATERIAL
Company Name ft in.
G OR TUBING(geothermal closed-log
2.Well Construction Permit#: (O 7 DLU QECER THICIQVESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft in.3.Well Use(check well use): ft — in.
[OAgricultural
ater Supply Well: 7.SCREEN
TO DIAME7'EP5ble
REI�Lll..EITI...
ERIAL❑Municipal/Public ft ftGeothermal(Heating/Cooling Supply) R�Residential Water Supply(single) —
fL fL❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑I1Ti ation ❑Wells>100,000 GPD FROM TO MATIMIAMOUNTNon-Water Supply Well: ft ft❑Monitoring ❑Recovery ft ftInjection Well: lJ r❑A uiferRechar e ft ft q g ❑GroundwaterRemediation❑Aquifer Storage and Recove 19.SAND/GRAVEL PACK if a lia
Recovery ❑Salinity Barrier FROM TO MATPRL,L OD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DR LLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soi0rocktype, in size,etc)
ft ft
4.Date Well(s)Completed: —�9 Z 3 Well ID# ft ft.
5a.Well Location: /� 1 ft. ft
tJ D t^q e_ G 0 7 �)O ft. ft
Facility/Owner ,mn
ae Facility M#(if ft applieable) ft
ac IV
(A CA, l l 1�LV ��C �l �� ".ft ft — J
Physical Address,City,and Zip ft. ft
21.REMARKS J —_
County Parcel Identification No.(PIN) _
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) —
22.Certification:
N �D a a �-7 W Ago&
6.Is(are)the well(s): Drermanent or ❑Temporary 3a Sianahue 6f erti5e Well Contractor 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 '1!5N. 15A NCAC 02C.0100 or'ISA NC4C 02�.9200 Well Construction Standards and that a copy
If tits 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 of this form.
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 Oved in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (o (ft.)
For multiple wells list all depths(different(example-3(200'and 2 a 100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing:_ (ft) 24a. For All Wells: Original forn to Division of Water Resources (DWR),
If water level is above casing,i se"+'/ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: l� (/� (in,) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:"
ethod,�p't p"1►ti _ A') 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.)
county environmental health departmer..t of the county where installed
FOR WATER SUPPLY WELLS ONLY:
/ 24d.For Water Well, producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) 1`Z Method of test Permit Program,1611 MSC,Raleigh,l(C 27699-1611
1,
13b.Disinfection type: f Amount:_
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6-2018