GW1--06437_Well Construction - GW1_20231009

WELL CONSTRUCTION RECO _ .(GW-1) For Internal Use Only: •
1.Well" ctor•Information: ' , •
i i� : • 14•M.WATER ZONES '
Well on..,tor, ," FROM TO DESCRIPTION
�59 7 /� a ft• vu ft
ft ft l. . ' .
NC Well Contractor Certification Number
a/��t / 15.OUTER CASING(for multi-cased wens)OR LINER(if ap linable) •
�c},0,//� FROM ft I TO ft. I DIAMETER. I THICKNESS MATERIAL
Company Name
3 C/ / 16.INNER CASING OR TUBING(geothermal closed-loop) •
2.Well Construction Permit#: // l • FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) f J ft s(v ft' �•,I/O1 in, 7 0/ /Q('✓
3.Well Use(check well use): ft. v It in. 6 ! a
Water Supply Well: - 47.SCREEN •
❑A COItuIal FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL • '
gn '❑Municipal/Public ft. ft. .. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) .
6 ft ft in.'
❑IndustriaUCommercial Residential'Water Supply(shared)
18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: •
O ft„_„Z 3,^tt-
• • ❑Monitoring . ❑Recove �' Q [ t"�
' • Injection Well:' ry
•
❑Aquifer Recharge ❑Groundwater Renmediation ft. ft.
❑Aquifer Storage and Recovery ❑Salmi Barrier • 19.SAND/GRAVELPACK(if applicable) '• •
tyFROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Storm water Drainage z ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft
• °Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO - DESCRIPTION(color,hardness,soil/rack type,grain size,eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
�/ ft. ft.
4.Date Well(s)Completed: Q u&3 Well ID# • ft. 'ft. •
•
•
5a.Well Location: ft. ' ft. • -▪ -
I�.uikf. e-DSS • ft. ft. '�''...rrl.,,f 'v r.
• Facility/Owner Name Facility ID#(if applicable) ft ft. O C T n 9 9023
421 -2 1-/11t c,cla ftc M4. 41' •• - --"ft ft •
Physical Address,City,and zip ft. • ft. 1;1;.;,,,-.�...z.-„ t�7„Y y�* m..2 l�C�_
Oil.t__
•
21.REMARKS
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.Certifi a
310 ' / ' 3 Z. N 8/' 30' 2 W
6.Is(are)the well(s): [ ermanent or ❑Temporary 3 ta, . C72-0.-:7:41b$4,72.3)
2. ' Signature bfC ell Contractor Date
Bysigning this form.I hereby cent&that the well(s)was(Were)constructed in accordance with
7.Is this a repair to Van existing well: : Oyes or,AcNo• - ISANCAC 02C:0100 or'ISANCAC 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 well owner.
'repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Rtniarks Box).You may also attach additional pages if necessary.
drilled:
2'6 24.SUBMITTAL INSTRUCTIONS .
9.Total well depth below land surface: LI- (fh) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdserent(example-3Q200'and 2@100)
• (ft) 24a. For All 'Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: / O
If water level is above casing:use/"+' r/ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 •
11.Borehole diameter: (�, a (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
/1� Program,1636 MSC,Raleigh,NC 27699-1636
•
12.Well construction method: 04 a►'I.+l I /'I 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: •
24d.For Water Wells pro duci I g over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) I Q Method of test: Cal___ ' Permit Program,1611 MSC,Raleigh,NC 27699-1611
it
13b.Disinfection type: �1 'lL Amount: 1 0 a'u-
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources '
Revised 6-6-2018