GW1--00049_Well Construction - GW1_20231218

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
1.Well Contractor Information:
MSC k, -50rnt j 14.WATERZONES
FROM TO DESCRWTION
Well Contractor Name
t 2 ft. $ci ft. /_ Gp�
D 51 C o ft. ft. 1p I
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
t A R A�wu S y Nc FROM TO DIAMETER!to THICKNESS MATERIAL
Company Name IT Oft. v I a7..i7'7i/� PVC.
16.INNER CASING OR TUBING(geothermal closed-loop) -
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(le.UIC,County,State,Variance,etc.) ft ft. in.
ft
3.Well Use(check well use): 1°
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural DMunicipal/Public ft' ft. In.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. In
DI Industrial/Commercial DResidential Water Supply(shared) 18.GROUT ,
irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. g a ft. Nlftr tt2 o l bs Po OA
Monitoring I3Recovery ft. ft.
Injection Well:
ft. R.
Aquifer Recharge ['Groundwater Remediation 19.SAND/GRAVEL PACK(if applipble)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test (jStormwater Drainage ft.
ft.
DExperimental Technology IOSubsidence Control ft. ft.
DGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
ri ,Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soi0rock type,grain size etc.)
CC ft f.
4.Date Well .
s)Completed: I -5-23 Well ID# ft ft. r^;
5a.Well Location: ft ft. iT 'y"' +�
GuivE14 ( .AN0ERs ft G ,.,.r,�
1
Facility/Owner Name t Facility ID (if applicable) ft ft 4 U[3
2063 SurT STORC Pb..b ft. ft. Ini.:irr.- ^a :.)''.^.r
sr; ,V;,+tit
Physical Address,City,and Zip ft. ft. �'` '1 �1°d v
GRAM 1.L� 21.REMARKS .�+
County Parcel Identification No.(PIN) I�AST 14U GO =AEA r OR 1.6RI(4 MML
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: a I4SZNCs
(if well field,one tat/long is sufficient) �j p 22.Certification:
No•/1OS23 N y lB.s44146Si1 W f i�r�
Isom )2.5.23
6.Is(are)the well(s)1Permanent or Temporary Signature of Certi ed well Contractor , Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: "Yes or ONo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy 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:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details.You may also attach additional pages if nereKsary.
drilled: SUBMITTAL INSTRUCTIONS 1
9.Total well depth below land surface: / 3 0 (ft.) 24a. For All Wells: Submit this!'form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following: '
10.Static water level below top of casing: / 3S (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Cf nter,Raleigh,NC 27699-1617
11.Borehole diameter: l/� (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: R Orr;Vi �� above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: p 1636 Mail Service Center,Raleigh,NC 27699-1636
D
13a.Yield(gpm) b Method of test: / u IM 24c.For Water Supply&Iniectt n I Wells: In addition to sending the form to
.f. the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 141.H Amount: ( 0 Z' completion of well construction tot die county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016