GW1--04380_Well Construction - GW1_20230707

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
7C(.501 POO It .14 WATER-ZQN1:S .v.,.. ,
FROM TO DESCRIPTION
Well Contractor Name
----)-1 ft. I o`U ft. /1 cj'p t�'1
ft. ft. J
NC Well Contract r Certification Number 'n 15 OTITER:CASING(for multi caseii'wellsyOR{LINER'`(If ap hca6le}
/^ ir/ p f it al
Ohl) (]5a FROM TO
E• DIAMETER THICKNESS MATERIAL
/fin (wt/' �J ft. r7 ft b m �l i l�.
Company Name
� j� 16:TNI+IER CASING OR TlSING(t ehthermaclaseop)
2.Well Construction Permit#• (W r V 1-3 o(6 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC, oun y,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROMREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural ❑Municipal/Public ft. ft. in.
DGeothermal(Heating/Cooling Supply) 4Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial DResidential Water Supply(shared) 18:GROt1T
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. ,�^ ft. b,,,,,j„-L1� ilitGL+i rallitY
OMonitoring ❑Recovery ft. L•� ft. �f�/
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation ..
19-SAND/GEtAVEL,PACK'(if applicable) , , 'a
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
- DExperimental Technology ❑Subsidence Control ft. ft.
D Geothermal(Closed Loop) ❑Tracer 20.;DRILLING`L OG(attachaddrtionalsheets,ifnecessaryj,
DGeothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
22ft. apt ft. 4-Q,,A
4.Date Well(s)Completed: (�-'1��"J Well ID# � ft. 16 D ft. V r��nG�i�� j-ok
5a.WellLocation: ft. ft. t/°' �-
1,041 /,a n i ( [^
ft. ft.
Facility/Owner Name r� Facility ID#(if applicable) ft. ft. pZ
7.R3 Leo & &` ft. ft. )', '; �...G.,,e a 4r a_•.!"'*
Physical Address,City,and Zip ft ft. 191, (1 r 7023
\tu ) 3d095 .21:REMARKS . ., _ .
County Parcel Identification No.(PIN) tti ",. ��
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W
6.Is(are)the well(s): Iermanent or ❑Temporary Sia ertified Well Con r Date
�/� By si ing this form,I hereby cert J that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or {'No 1SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information anaaa 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: t 0 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Gj (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdii different(example- 00'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: VO (it) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: (9 (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(1UC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: a f 0 t '1 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: r 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
KJ� F� Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:13b.Disinfection type: 11/4 4 Amount: 1 J
i X a
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018