GW1--04814_Well Construction - GW1_20230721

WELL CONSTRUCTION RECO (GW-1) For Internal Use Only:
• 1.Well tor-Information: .
14.WATER ZONES
Well Contrac c2 FROM TO DESQtiP1IOPr --
•
y5q 7—/1 MD �ao
ft
. ft it
•
NC Well Contractor Certification Numb
�/C ' , �1 t 15.OUTER CASING(for multi-cased wells)OR LINER(ifap linable) •
I. UL/V me Yn OVJA� - �,✓ FROM TO DIdMEIFdt THICKNESS MATERIAL
Company Name /� in
fJ 16.INNER CASING OR TUBING(geothermal doted-loop) •
2.Well Construction Permit#. FROM TO' DIAMETER THICIO�lESS MATERIAL
List all applicable well construction permits(l a UM,Cosmry,State,Variance,etc) .. I ft 94,
ft. 6.%i In.
7h i C K Pir-..•
3.Well Use(cheek well nse): ft. ft. is
•
Water Supply Well: 47.SCREEN
• ❑A Cultural FROM ' TO ti DIAMETER SLOT SIZE,' THICtOYESS MATERIAL
gn •❑Mtmicipal/Public ft _ ft. in.
10Geothermal(Heating/Cooling Supply) 4esidential Water Supply(single) .
R ft ' in;
❑Indushrial/Commercial ❑Residential•Water Supply(shared)
ho IS.GROUT
❑Irri
• n ❑Wells>100,000 GPD . FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: • 0 ft �3 ft -
• ❑Monitoring ❑Recove Mar t
• Injection Well: fe
a.ri(1iA p(.s.rr-i AA
❑A utferRech ft ft
q arga ❑GroundwaterRemediation
❑Aquifer Storage and Recovery . ❑Salinity Barrier . • • FROG/GRAM TO L PACK CMATE�Le) •
EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage . ft. ft
❑Experimental Technology ❑Subsidence Control • ft ft.
•
• ❑'Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO • DESCRIPrION(eSter,hardacu sail/rockerpe,�aesae eta)
h ft
4.Date Well(s)Completed: 7 "3,23 Well ID# • ft it .
•
5a.Well Location: ft • ft.
-
All aSIQdI,0rCc{ 1BU.lid ft ft
• Facility/Owner Name FacilityID#(ifapplicable) ft ft
N•-�• �Urt'rr 1�1 V�L. 1� a'►' • •..ft ft. C' D
� Its+
Physical Address.CRY.and Zip -ry 3 h. 1 - l.? ft ft.• JUL 1 2fl ,q
A5)-1 / ,21•REMA.RILS./ 202�
County. Parcel Identificatioallo.(PIN) • �en Pry
rteWCILI
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: iaiiIT
(if well field,one lat/long is sufficient) 22.C I
t3/'. aq • /Le. N g/ ` 27 •
I
.6.Is(are)the well(s): f?ermaneut or ❑Temporary �3 d Si ��7 2-3
` goat re ofC.::. ell Contractor Date
•
7.IS this a repair to an existing 31 - By signing thtrform,Iherebycertifythat thewell(s)was(were)constructed in accordance with
P well: ❑Yes or , io ISANCAC 02C:0100 or2S:1 NCAC 02C.0200 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 Oft record has been provided to the well owner
'repair under#2!remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DP1'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 o
drilled: pages if necessary.
•� 24.SUBMITTAL INSTRUCTIONS '
9.Total well depth below land surface: es/a d (IL) ,
For multiple wells list all depths tfde:arent(example-3Q200'a^and2@100' Submit this GW-1 within 30 days'of well completion per the following:
10.Static water level below top of casing. /�O • ft 24a. For All Wells: Original foam to Division of Water Resources (DWR),
Ifwater level is above earin&;u e"-- (ft)
.). Information Processing Unit,161,=7 MS• C,Raleigh,NC 27699-1617 •
VY
11.Borehole diameter. .Cm) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC Program,1636 MSC,Raleigh,NC 27699-1636 )
12.Well construction method: •
(ix.auger,zotasy.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.For Water Wells producing over 100,000 GPD:Copy toDWR,CCPCUA
13a.Yield(gpm) 3-5 Method of test at, Pelt Program,1611 MSC,Raleigh,NC 27699-1611
�17 /o _ ;,
13b.Disinfection type: Amount: /0 sv
•Form GW1 NarthCamlinaDe.,■.�,,,..,.,.fr.„. __��r......•.