GW1--05629_Well Construction - GW1_20230831

• i..
WELL CONSTRUCTION RECO (GW-1) . . • For Internal Use Only:
1.Well tractor•Inf oration: •
' • •14•WATER ZONES
II
Well Contractor Name _ -. FROM TO • DESCRIPTION
• �3535 1 Hof 31b ft ' ; '
NC Well Contractor Certification N bet ft • ft
' naorhapv • 15.OUTER CASING(for multi-cased welts)OR LINER(if ap licable)
FROM • TO DIAMETER THICKNESS MATERIAL
Company Name • ft J. ft J
in. J
.
2.Well Construction Permit#: 7 8.3 16.INNER CASING OR TUBING(geothermal dosed-loop)
FROM TO DIAMETER THICKNESS MATERIAL List all applicable well construction permits(I.e.UIG Conn°,State,Variance,etc.) -f r ft I0 ft: 5 7,,,/ in.
o � Jj L, �
f� iTh 3.Well Use(check well use): ft, ft
Water Supply Well: 47.SCREEN P
• ❑Agricultural PROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Municipal/Public" ' ft. ft , j, M.
❑Geothermal(Heating/Cooling Supply) -11Rtsidential Water Supply(single) •
❑Industrial/Commercial 1°
❑Residential'Water Supply(shared)
❑Irrigatioq 18.GROUT
❑Wells>100,000 GPD •FROM 'TO -. MATERIAL EMPLACEMENTMETROD&AMOUNT
Non-Water.Supply Well: •" ' Q fa 23 ft. Neat. .Ail - c,f
• ❑Monitoring ❑Recovery • ft t L
Injection Well: 11)rill"vt' ,�
❑Aquifer Recharge ❑Groundwater Remediation ft ft •
❑Aquifer Storage and Recovery ❑Salinity Barrier • ' 19.SAND/GRAVEL PACK Cif applicable) •
FROM TO MATERIAL EMPLACEMENT METHOD
['Aquifer Test • ' ❑StormwaterDrainage ' ' ft ft
1 '
❑Experimental Technology " OSubsidence Control , ft n ';
• ❑Geothermal(Closed Loop) . ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
CI Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks) FROM TO • DESCRIPTION(color,bardoest,aa;vmcktype,Rniosite etc.)
ft. tt
4.Date Well(s)Completed: c'II'1i.3 Well ID# ft ft
Sa.Well Location: ' • ft ft
• 1 r.� vi Sc c . ' " • ft . '" .
• Facility/Owner Name Faculty ID#(if applicable) " ' ft ft
Toe 1.11 n 4" Rd : Lat.1y- ) 5Pr I I, •R,M1.I -'m , ft • AUG 3 2023 _
Physical Address,City,and Zip ft ft ; jFl{ Chit fa C.yg�(I tr►rui
• • I in '� \t • .
' 21.REMARKS! f ++.
•
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i
(if well fie d,one lat/long is sufficient)
3- �A 22.Certific lion: i
,A'% ,A5 N $ ! O^�•D• at) • - W
ItgAriet f - 23 ,z3 _
6.Is(nre)thc'well(s): ci ermanent' or -❑Temporary. - -31 q-o i --Signature ofCerorr d'•Well Contractor Cd Date
- 1 By signing this form,Thereby certify that the wells)war(were)constructed in accordance with
• 7.Is this a repair to an existing well: ❑Yes or 19No • ISA NCAC 02C:0100 or 5ANCAC 02C.0200 Well Construction Standards and that a copy
!phis is a repair,fill out known well construction information and explain the nature of the alibis record has been provided to the well owner.
'repair under 021 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 Rdniarks Box).,You may also attach additional pages if necessary.
• drilled:
• 24.SUBMITTAL INSTRUCTIONS '
9.Total well depth below land surface: 3 2.6 - 1(ft) ' •
For multiple wells list all depths((different(example-3Q200'and 2QI00) Submit this GW-1 within 30 days:of well completion per the following: -
10.Static water level below top of casing: �-� • (ft) 24a.•For All Wells:. Original'form to Division of Water Resources (DWR),•
Ifwater level is above casing;:ute"+• Information Processing Unit, MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6r/� 24b.For In Wells:Co to
• `Cn•) Py DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636 " •
12.Weltconstruction method:
(i.e.auger,rotary,cable,diredpush,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 to DWR,CCPCUA
13a.Yield(gpm)' ' 15 Method of tests am;
AA • - Permit Program,1611 MSC,Raleigh,NC 27699-1611
1�7I� - ,t
13b.Disinfection type: Amount: • - •
•
•
Form GW-1 I.
North Camlina Department of Environmental Quality-Division-of Water Resourcesi '
p Revised 6-6-2018