GW1--07488_Well Construction - GW1_20231120

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1_Well Contractor Information:
p f11A tR. A.12.11 ,et j 14.WATER ZONES
Well CoMmctorName FROM TO DESCRIPTION
qr ft. 100 R• iO Jem
3E-,-41 t 8r R. 1R It. !o p%v
v lls
NC Well Contractor Certification Number IS.OUTER CASING(for multi-case )OR LINER(if ap limbic)
-/ + I \ 1 t FROM TO DIAMETER THICKNESS MATERIAL
[ .t7�1-dtl(S Wilt -I,f`t 1�1 6 KC , 11-- it. '7 ci rt. 6'�`'( in. +Thai irc.:Company Nanfle '1 4 Sl rp to l 1 V ,- v, At Z�a f +
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: .3'39 G1 _ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UiC.County,State,Variance,etc.) fL ft. in.
3.Well Use(check well use): ft. It. in.
Water Supply Well: 17.SCREEN N j
FROM TO DIAMEtER SLOT SIZE THICKNESS MATERIAL
❑Agriculluml ❑Municipal/Public ft. It. in.
❑Geothermal(Heating/Cooling Supply) 1)4Residential Water Supply(single) rt. rt. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) is.GROUT
Oh-Ligation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. 3 ft. etine. 7,...,....pzd
❑Monitoring ❑Recovery 3 ft. 2.0 f.t
bpl tl4 I z. uvL ra
Injection Well: ft. R.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable) Al II,
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLaCE3IENT 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 DESCRIPTION(color.hardness,soil/rock type grain srze,etc.)
n ft. r 0 ft. 4
.1' re-c� se r 1
4.Date Well(s)Completed:i i I I V(AettA 3 Welling 3 2`7 to R 5 10 ft. 4 0 ft. l-e_f rw_t_ SE t i f
5a.Well Location: 0 It' ' S It `(ell sW Secerrn en ✓4 1�8
�. -7 S� ft. 21,4 5-IT. �,,(1, tit 1
W a).hd eL i e ii act 45 .;5 -
Faciliry/OwnerName Facility i1#(if applicable) ft. ft. '
-
`d t 1-L F h t r�f-74. O k F✓- T 2.rtS-1,, It. It. i, - ,- .
Physical Address,City,and Zip / t t, ft- ft. ' • - .� ..g Ti-.__,, `:.9`?r",
6--r,�� i Ll� 21_REMARKS NOV n
,
19s-$90`�L-1 ntog NO 2[123
County Q Parcel Identification No_(PIN)
Iflf:2:1:,.`,',^: t:1:.--2.--j-J i':"a
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certification:
36, 717 leS-4 N 7&•31 -c) W .--g �\ . lr
6.Is(are)the well(s): Permanent or ❑Temporary - Signature Certified 'kttorCo Da
By signing.this form.'hereby certify that the well(s)was(were)constructed in accordance with
7.is this a repair to an existing well: ❑Yes orro 15A IVC,IC 02C.0100 or I SA N'CAC 02C.0200 Well Construction Standards and that a copy
IJ t/tis is a repair,fill out knownwell construction information and explain the nature of the of t/us 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 I'GVV-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS •
9.Total well depth below land surface: oZ 0 S (ft.) Submit this different GW-1 within 30 days ofwellcompletion the following'
For multiple wells list all depths erent(example-3(a)200'and 2(6)100') y per
if
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 0 (ft) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing.use"+"
11.Borehole diameter �� (in.) 24b.For Injection Wells:Copy to DWR,Undetgtound Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: A l iZ IZ.e'71?-iZ 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 producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) A CD p fMethod of test: r_g t 1
13b.Disinfection type: tj,(),{�'1�111Orj+e. Amount: tp 0•.-
J! 1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 6-6-2018