GW1-2023-02813_Well Construction - GW1_20230417

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor information:
0 14.WATER willw
FROM =M06DESCRWIHON
WelllContractoorName ft.ft.
NC Well Contractor Certification Number 15.OUTER4 ;ndls ORT;IIYER :a cable•,
51HNIN-f"ER
TO DG►METER' THICIffHESS MATERIAL
i t,r]�UiaS/w ►I t��i L( i it -- ft. in. ✓(i
Company Name —�- ASINGOR T eotheemalTO DIAME ER THiCICNESs MATERIAL
2.Well Construction Permit#: ft.List all applicable well construction permits(i.e.UIC,County.State.Variance,etc.)
ft in.
3.Well Use(check well use):Water Supply Well: TO DIAMETER SLOT SiZE THICJKNEss MATERIAL
Agricultural [3Municipal/PublicC� ft `L- in u 4)(0
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft, ft, in.
Industi ial/Conimercial oResidential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Irri ation
Non-Water Supply Well: © fL I ft. /�t.la4 i e (7(�d1
Monitoring Recovery fL j ft
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL RACK s licalite
Aquifer Storage and Recovery Salinity Barrier P240.
M TO MATERIAL EMPLACEMENT METHOD
�Stormwater Drainage ft. L� ft. lr Ill/✓/-el -
Aquifer Test g
Experimental Technology Subsidence Control B• fL
Geothermal(Closed Loop) Tracer G LOG >tldl!#dailsLeets#f:ueisa .M TO DESCRWFION color,hnrdft2%sGiVrock type,grain sue,etc.)
Geothermal(Heatin Coolin Return) Other(explain under#21 Remarks) ft. I g 0 5 •1
4.Date Well(s)Completed: `'( �3 Well ID# 2 l 1t M I ft.
fL ft.
Sa.Well Location:
Facility/Owner Name Facility ID#(if applicable)
ft d
/ ft. tt
q0D fL ft.
Physical Address,City,and Zip
21.. ... i • -1ltt
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
(if well field,one latllong is sufficient) 22.Certiflch on:
N �77. 1 �5 W �j ' rlS� 2-3
j I
r cure of ertified Well Contractor Date
6.Is(are)the weil(s) Permanent or emporary
By signing tits' form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or �No with ISA T.t ..C 02C..0100 or ISA NCAC 01C.0100 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this r7ord 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 t,eoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide.additional well site details or well
consauctio details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells I
drilled: SUBMI INSTRUCTIONS
9.Total well depth below land surface: (ft•) 24a. For Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Qa 200'and 2(a3100� constructio 1 to the following:
Io.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
0f water level is above casing,use"+"/ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (tn.) 24b.For Thiection Wells: In addition to sending the form to the address in 24a
above,iscFsubmit one copy of this form within 30 days of completion of well
12.Well construction method: �� constructiO to the following:
(i.e.auger,rotary,cable,direct push.etc.) I
Divisioµ of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: ! 1636 Mail Service Center,Raleigh,NC 276"-1636
i
13a.Yield(gp ) 24c.For Water Supply&Iajection Wells: In addition to sending-the form to
m Method of test: .
the addreriio(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount completion of well constructibm to the county health department of the county
where constructed.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016