GW1--03739_Well Construction - GW1_20230602

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
L"Well Contractor Information:
r\ :VVa1TERs�U1`1R$
Well Contractor Name Q FROM TO DESCRIPTION
ft. %
NC Well Contractor Certification Number 11i;OUTER-,CASING fo'rmulh-cased.vvells;bR'IiINER'if a""'ll`ca61e
- FROM TO DIAMETER THICKNESS MATERIAL
Company Name ft y,oft. In ® ! AJ� Z
/�,L,( ;16:;1N1VEft CASING.OR�T[1SIN.G eothermelietosed=toa .....,:. : i.�r.,.: ,.;_
2.Well Construction Permit#: 1�- V`/.l)✓tO FROM TO DIAMETER THICKNESS MATERIAL,
List all applicable well construction permits(I.e.UIC,Couno,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well
FROM TO DIAMETER SLOTSIZE THICKNESS!` MATERIAL~
❑Agricultural ❑ unicipa]/Public it. ft. In.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL fr. in.
❑IndustriaVCommercial ❑Residential Water Supply(shared) 'IB GROUT :: `=
t
❑Irri ation ❑Walls-100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water-Supply Well: ft. a.0 ft. r
❑Monitoring ❑Recovery ft. ft. Of
Injection Well: ft. tt.
❑Aquifer Recharge ❑Groundwater Remediation
r19:SAND/GffAYEL PACK',f n"lieabie t'•, ','s;,;
❑Aquifer Storage and Recovery d alinity Barrier FROM To I MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer z0 DIt1YSI;IN fOG att3cli'additi'o"nuI sheets'i€necess' ;+' a
I'll Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,solUrock typt,gr2in size,etc
fr. C'
4.Date Well(s)Completed: "7 �� r Well ID# too ft. L
5a.Well Location: I I/ ft. ft.
l i YN �f ! r'� rt. rt. l I s 927023
Facility/Owner-Name ac'i ID#(if applicable) ft. ft
11155 _ s
,i , .... .
rt, rr.
Physical Address,City;an Zip114 .
,°7• 1 :.�.I:'N..:I�iAS t:it}v . ,'.i .�....._Y Q }..'..Y.S.' ....:.'ti.. .._ T�. !h
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C
N W
6.Is(are)the well(s): Lhermanent or []Temporary'-. Sign a of Certi fed 11 Contractor Date� 2
� -y..e; .g:a:,IuiTe,L i,ci euy Lei i jy i/lal Tiro weiiis%was(were)eansir'uciea in accordance wan
7.Is this a repair to an existing well: ❑Yes or IX&O 15A NCAC 02C.0100 or 15A NCAC 02C A200 Well Construction Standards and that a copy
If this is a repair,fill out brown well construction information and explain the nature of the of this record has been provided to the well owner.
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
:.......,...;.tl,.� ;.�I..t /?\l)1 �� -] T,,;f:.�-F_mr�7. �,r n,�r�� (art �CPP IPr'irk Rprrrvrlre Rnyl Vn.... elo_n++p I,n.t.ilti,.....1.. :l`.....__
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ilritled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 4 N� ft
For multiple wells list all depths if dVer•ent(example-3Q200'and 2Q100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: Q (1t 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
11.Borehole diameter: (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
( Program, 1636 MSC,Raleigh,NC 27699-1636
- -- - /t i ✓' r a#n��uI
tic.i ur ri uier iiuppiy anu open-loop 13 iaermai xeturn wells:Lopy 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
�j 13a.Yield(gpm) Method of test: V Permit Program,1611 MSC,Raleigh,NC 27699-1611
Q p 1-
13b.Disinfection type: Amount: .7"� l L