GW1-2023-01819_Well Construction - GW1_20230223

WELL CONSTRUCTION RECO GW-1 For Internal Use Only:
1.Well Co�ntra�ctor.Information:
L
5-1 rm �il�� 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
ft p ft
NC Well Contractor Ceti cation Nnmber ft fL
IS.OUTER CASING for multi, d wells OR LINER rf a linble
n nil �.�{� FROM TO DL11vIETER THICKNESS MATERIAL
Company Name ft ft in
16.INNER CASING OR TUBING' eeothermal closed-loop)2.Well Construction Permit4: O�p-7� tV - FROM TO DIAL ErER TffiCKNESSI MATERIAL
List all applicable well construction permits(Lc UIC,County,State,Variance,ere) fL
'7 fL in
3.Well Use(check well use): ft ! ft —9,_ M
Water Supply Well: 7.SCREEN❑Agricultural - FROM TO DIAMrJTP_ t4 _t
MATERIAL
❑M_—u-nicipaUPublic fc ft in❑Geothermal(Heating/Cooling Supply) idential Water Supply(single) ft ft in❑I riff aUCommercial ❑Residential Water Supply(shared)❑Irri flan 18.GROUT
❑Wells>100000GPD FROM To NAn,: IDdrAMOUNfNon-Water Supply Well: ft fc❑Monitoring GRecovery
Injection Well: fc fL r
ti
❑AquiferRecharge ❑GroundwaterRemediation ft ft
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK da liable
FROM TO MATIRUL EMPLACEMENTMETHOD❑Aquifer Test ❑StormwaterDrainage fL ft
❑Experimental Technology ❑Subsidence Control ft. fL
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) IxoM TO DESCI IP rION eater,hardnw soiVrnck is sae ctc.)
ft ft
4.Date Well(s)Completed: 1-Z 7.Z3 Well ID# ft ft
5a.Well Location: fc ft
ft. K —
Facility/Owner Name
I��C1 ft A n �1f�1 Facility ID#(if applicable) ft
11L /V1.Ck- 1 Cq �Y11 LO - 144 fL ft
Physical Address,City,and Zip ft —
ft
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient)
22.Certification:
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N W --
-/�F-23
6.Is(are)the well(s): ermanent or ❑Temporary 6/ Signanue e'd'•We star Date
7. By signing this form,I hereby certify that the we!!(s)w¢r(were)constructed in accordance with
f Is this a repair to an existing well: ❑Xes or �iQo ISANCAC 01C.0I00 or'ISANCAC 02t7.0200 Well Construction Standards and that a copy
lfthis is a repair,j(1 out known well construction information and explain the nature of the of this record has been provided to the will owner.
repair under#11 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 ifnecessary.
drilled:
Z O 24.SUBMITTAL INSTRUMOISS
9.Total well depth below land surface: (ft)
Formultipie wells list all depths,fdrfj'erent(example-3(200'and 2Q100D Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: D (ft) 24a•-For All Wells: Original form to Division of Water Resources.B r level above eosin&:vse•+/ \
11 Information Processing Unit,1617 NBC,Raleigh,NC 27699-1617 ��)�
11.Borehole diameter: l/'� 0✓ .(in) 24b.For Injection Wells: Copy to MR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 2;659-1636
12.Well construction method:.JP Q'f"a wt _ An--(i.e.auger,rotary,cable,direct push,etc-) 24c.For Water Supply and Open-1—oup Geothermal Return Wells:Copy to the
county environmental health department of the county where installed
EDisinfection
UPPLY WELLS ONLY:
_ 24d.For Water Wells prodncine o"er 100,000 GPD: Copy to DWR CCPCUA
(- Method of test Permit Program,1611 MSC,Raleigh,NC 27699-1611
L ys
type: 7 Amount
Form GW-1 North Carolina Department ofEnvironmeutal Quality-Division of Water Resources
Revised 6-6-2018