GW1--07806_Well Construction - GW1_20231201

WELL CONSTRUCTION RECO (GW=1) For Internal Use Only:
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1.Wel tractor.Information:
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• r. • ,±4:._...' . - •14. •
WATER ZONES .
Well Contractor FROM TO
DESCRIPTION
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5��"� • ).0 N6af�
ft. ft. 1
NC a Contractor Certification umber •
/ � � ry ��/ram/tom 15.OUTER CASING(for multi-cased wel6).OR LINER(lisp licable)
X, (�r.�� FROM TO DIAMETER 4 THICKNESS MATERIAL
Company Name `mil / 11 I 1
] / ' 16.INNER CASING OR TUBING(geothermal closed-loop) •
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2.Well Construction Permit#: 3 '-f� ( FROM TO DIAMETER THICKNESS MATERIAL List all applicable well construction permits(I.e.UIG Cows tate,Va once,etc.) I II gi fL ✓`!7( /,) ia, �)fl f c-i l ?y(/�
3.Well Use(check well use): ft L ft in.
Water Supply Well: • 47.SCREEN
• ❑A cultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
.0Municipal/Public ft ft. in.
['Geothermal(Heating/Cooling Supply) sidential Water Supply(single) •
❑lndustrial/Commercial ResidentialWater Supply(shared) ft. ft ln.'
❑Lri lion • 18.GROUT
❑Wells>100,000 GPD FROM . TO MA EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ^� f4 �� a T ^►L
❑Monitoring ❑Recovery - V ft. f� /•`/o r L f a�4
' Injection Well: T
❑Aquifer Recharge ❑GroundwaterRemediation ft. R
['Aquifer •Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK(if applicable) , •
FROM TO i MATERIAL, EMPLACEMENT METHOD
❑Aquifer Test ❑Stomrwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft
• l7Geothermal(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/reek type,grain size,eta)
ft.
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4.Date Well(s)Completed: 11 17 23 Well ID# ft. Yt.
� .r»4-4 1-4.. C .) ri Jl~)-
Well Location: ft. ft.
• rem L S cI e ee 1-eu x4� u_c- ft. ,� ;r;1..-:.,r
• Facility/Owner Name Fa�MI/(if applicable) ft R n r r
• Mill C t i ►� J - /v d ® • n L •--ft. f. • •� j 2L�23
Physic Address,City,and Zip ft. ft ina,l,h,3e:3F1 r-'roc. 'g.ng lit
21.REMARKS lr rr��}}�! y-�`
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one let/long is sufficient) •
3 6' 17 5 2 5� 22.Cer', n: _ i
N ei , 3.3 ' / � W - .0 °
6.Is(are)the well(s): l rmanent or OTemporary . 3 06a , Signahue of J art •',ell Contractor Date
7.Is this a repair to an existing well: ❑Yes or NoI • S NCAC 02C:0 00 0 ISAN Cr 02C.0200 hat the (]Yell Construction Standards and was(were)constructed in thhat a copyl
Ifthis is a repair,fill out broom well construction information an lain the nature of the of this record has been provided to the well owner.
'repair under#21 remark section or on the back of this farm.
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:
24.SUBMITTAL INSTRUCTIONS i •
9.Total well depth below land surface: 6 . (ft.)
For multiple wells list all depths if different(example-3( 200'and2®.100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 24a. For All Wells: Original form to Division of Water Resources (DWR),"
'Twofer level is above casing,:use"+'l�� 80 (f t) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 - •
11.Borehole diameter: / (in,) 24b.For Infection Wells:Copy to DWR,Underground
W ��1 Program,1636 MSC,Raleigh,NC 27699-1636 Injection Control(IUC)
12. eltconstructionmethod: I�1�L�1 ��A
(i.e.Wei,rotary,cable,direct push,etc.) f 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the ' '
augecounty environmental health department of the county where installed
• FOR WATER SUPPLY WELLS ONLY: 1
24d,For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 3 Method of test: CIA.11- Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: H ' EA Amount: 1 2.-
Form GW-1 North Carolina Department of Enviroan ental Quality-Division of Water Resources
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Revised 6-6-2018