GW1-2023-02940_Well Construction - GW1_20230425

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
1 Q 5 o8 k. I4 W 0.TEIt Zt?1VES h ";.
Well Co actor Name FROM TO DESCRIPTION
ft. 0 ft.
ft. ft.
NC Well Contractor Certification Number
15,OCJ�TER CASINry for'mulh cased'wells OR_LINER'if a L"cable �a• ,_ :.<
J FROM TO DIAMETER THICKNESS MATERIAL
W•Q S II 7 �t'yly p ft it ft. I iin.
1.
V C
Company Name 16.•INIYER CASLN/GL OR TU uLVG 'ehthermal'clased loo`
2.Well Construction Permit#: "`� d / 10 6�� d Z� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. I in.
3.Well Use(check well use): it. ft. in.
Water Supply Well: FROM
xS TO DIAMETER, SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public it. it. in.I
[]Geothermal(Heating/Cooling Supply) NIRsidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 28.GROi1T _f
❑hTi ation []Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. Z ft. A r�V
❑Monitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19 SAlYD/GRAVELPACK` tfa' licb.[e
❑Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stotmwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20..DRILLING :OG attac>i,a8ditional sheets,if necessdr' `" ._ _
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO nEscRrPTI N color hardness,soiurocic e, rain size,etc.
4.Date Well(s)Completed: e 2-3 well ID# yp ft, it. r ti rfz
ft. ft.
5a.Well Location: I
ft. ft. n - 1'
9 f
Facility/Own`er Name Faciillliityy ID#(if applicable) ft. ft.
��'[ l tA,��`�1&� r� i 041�Ci ft. ft. APR 5
Physical Address,City,and Ap ft. ft. Il14t?tq i:.:'4N}t'dJ�fl.`:
r=& 17 7q a f t 7 S0 z�.1 iKARIcs,:
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 W
6.Is(are)the well(s): ❑Permanent or ❑Temporary Sigma ---erti- d W-11 Contractor Date
By •ning this form,I hereby certify that the we/l(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 4o 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis 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 Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 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 ifdierent(example-3@200'and 2@100')
10.Static water level below top of casing: '7,0 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: U Qjr If 6TO Y Y 24c.For Water Supply 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 GPD: Copy to DWR,CCPCUA
6 J Permit Program,1611 MSC,Raleigh,iNC 27699-1611
13a.Yield(gpm) I^ Method of test: 1
13b.Disinfection type: °, Amount: Z I eJ
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018