GW1--04382_Well Construction - GW1_20230707

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: •
1.Well Contractor Infor ation:
/a5®A ,p1 t/ 14 WATER ZONES _
Well Contractor Name FROM TO DESCRIPTION
1�1 et A . ft. a LI0 ft. 3 f f..
ft ft
NC Well Contractor Certifi tton Number '/�J ,r, I$.,OI•T>fER CASING 661filltt-casein;:wells 01f1:,11�/Wif aii haa6le)
( r,_ .A ro O I� \Ju I I ti r k,/IA f I )/ FROM ft. TO+/ ft. DIAMETER to THICKNESS MATERIAL
Company l.Name 1. ! 1 YY� �/V ® S / {� 4 I in `r�
k•f { i ;16.INNER CASING OR:TUBING(geothermal'closed loop) =V
2,Well Construction Permit#: W 1 Q f/ �� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipallPublic ft. ft. in. - - ,
❑Geothermal(Heating/Cooling Supply) {QResidential Water Supply(single) ft. ft. in. '
❑lndustriallCommercial ❑Residential Water Supply(shared) IS..GROt1T - - _
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EiVIPLACEMENjT�METHOD&AMOUNT
Non-Water Supply Well: (j ft. '2 0 ft. Qfh'�Ijy(tl (, i f1� y+
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19-SAiJD/GRAVFL PACK>(tf applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
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❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 2(1 DRILLING-E'OG(attacli additional:sheets-if necessary)' ..
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DEsc TION(color,hardness,soil/rock type,grain size,etc.)
1 I /� p ft. ,r 6 ft.
4.Date Well(s)Completed: — ! 2,! Well ID# ut7� ft. Y ft. ^
ft. ft. 3 r 'y -I.'?. a 11^"t,
5a.Well Location: �Es
it tfr V�S ft. ft. '1
Facility/Ownneer Nam Facility ID#(if applicable) ft. ft. i iJ i 0 7 2O L J
f Ob (!U/t—�f 841, it '1't./ itW l ft. ft.ft. ft. 1If, �' t�r',t
.;%::):�+.�
Physical Address,City,and Zip
\kt(kr t C q l 3 S 1Q el U 1 Citt 21.12ElcIARK$ , _ _ ,s. .
County Parcel Identification No.(PIN)
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one la/long is sufficient) 22.C ''cation:
N W 77- 5- ,3
6.Is(are)the well(s): Permanent or OTemporary of e if d ell Contractor Date
y 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 111No 1SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the ivell 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: I- ' 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 if different(example-3@200'and 2@100')
2-t5 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"//
11.Borehole diameter b (in.) i 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 1' Yl 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: rfit,/ 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm)
C�� Method of test: "�t foil- Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: ►V4' ff Ypp1 Amount: riz_ lb.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018