GW1-2023-02984_Well Construction - GW1_20230425

WELL CONSTRUCTION RECORD (GW-I) For Internal Use Only:
L Well Contractor Information:
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3d r1TER': OAIES' e
FROM TO "F ....� :. `i.,a .;. g +:;i,+,F )��,.�+�,., ..?`X
Well Contractor Name DESCRIPTION
Lal1 ft. o ft.
,
NC W ll Contractor Certification Number ft.
r 4L ►/�J /� 15.;AUTi;R5C 1SIPfG. of 5ndlh a€d wells'sTfR LWER`its"Gcatire " ?;::r
Pole,/41 W e l) � ( �,�(t+ � FROM TO DIA TER THICKNESS MATERLII
Company Name 1 N 0 ft D ft. In
n C
!i( o 61 1 :INi�IERC.ASING OR,T;IJBING`r'eutliertn'el`closeti lii'
2.Well Construction Permit#: UU ` FROM TO
DIAMETER THICKNESS MATERIAL
Last all applicable well conshvctton permits(i.e.UIC,County,State,Variance,etc.) ft. ft. In,
3.Well Use(check well use): tt. ft. in.
Water Supply Well: I ':SCREEN
FROM TO DL METER SLOT SIZE THICKNESS MATERIAL ..
❑Agricultural OMunicipal/Public tt. ft. in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single)
1t ft. m
Ulndustrial/COmmercial DResidential Water Supply(shared)
.vC�ROU� ,�_.:= __Ys,Y.�
❑Irri ation ❑Wells>100 000 GPD' FROM TO TERIAL FrvIPLACEMENTi"TROD& u�fOIINT"
Non-Water Supply Well: O ft. ft• r ®h 1'Ct(f
❑Monitoring ORecov t
ety ft. fL
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation ft. R'
OAquifer'Storage and Recovery ❑Salinity Barrier 19WSANb/GR4'�E.1'A' If ifs'""Iielbte „
FROM TO MATERIAL EMPLACEMENT METHOD
OAquifer Test ❑Stormwater Drainage ri. ft
❑Experimental Technology ❑Subsidence Control ft. ft. `
❑Geothermal(Closed Loop) ❑Tracer 3d:;bRltLTi+IGt1;DG atxachaddrtinnalsLcets?if`necesn
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) EOM TO ft DESCRIPTION color,hardness sotr/rock e, rain aize etc T
rt. -3_ ^
4.Date Well Z-3s)Completed:�_ Well D]# ft.. 'a Q it.
".
Fr'
Sa,Well
�Location
f� r ft. ft.
ft. ft.
Facility/ljv6ner," ne 11 Facility ID#(if applicable) ft• ft.LAJ, ft. ft.
Physical?ddress,`City;andZip ft ft
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 �Z3
6.Is(are)the well(s): Permanent or 'emporary Signature o Certified 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 No ISA NCAC 01C.0100 or ISA NCAC 01C.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 io 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.
'dti(ind: "1
. -,�"� 24.SUBMITTALII�"'TRUCTIONS -
9.Total well depth below land surface:_ c�. (ft.)
For multiple wells list all depths if direrent(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: �D 24a. For lls. Original form to Division of Water Resources (DWR),
Ifwater level it above casing use" (ft-) Information PioLcSsing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: Copy to DWR,Underground Injection Control(IUC)
1/ Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: t P
(Le.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.Far Water Wells roducin aver 100 000 GPD: Co to D
k Permit Pro PY WR,CCPCUA
13a.Yield(gpm) Method of test: �" Program,1611 MSC,Raleig ,NC 27699-1611
i
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources F.a-,)ni o