GW1--01283_Well Construction - GW1_20240229

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
1.Well Contrapcctor Information: +
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Well Contractor Name FROM pTO DESCRIPTION
�� 1a ft. N®0 ft. , 9.!® to
ft, I .. !
NC Well Contractor Certification Number
1;K:'OUTEIt CASING(fiimltltt:-rasedawelis)i0.1Wt!T R(tfap lrea6pe) r �:;~ . ...g.S
CI ®� FROM TO DIAMETER THICKNESS MATERIAL
flitRevel" 60 n. I I <des, �•.� 2,_ d;
.Y ,...u, y•y ' ' 4n 4 t • n to ullfGDp7`Yi
p r1fi,Yield' SIiYt ;tiit.eifIG(gebthectiis1 close =1Ciidp..".z .;} r t
2.Well Construction Permit#:C tI` q 5 S 5 'L
FROM TO DIAMETER �THICKNESS MATERIAL
List all applicable well construction permits e.UIC,County State,Variance,etc.) ft. ft. ' in.
3.Well Use(check well use): ft. ft. I in.
Water Supply Well: N'�7�;;SGREEN:�:.�. �. .` V,t" :,f�:; Y� , • z� I ,F
t FROM TO DIAMETER SLOT SIZE THICKNESS MATERLAL
❑Agricultural D Iunicipal/Public ft. , ft. 1n.
OGeothermal(Heating/Cooling Supply) Residential Water Supply(single)Y(sin g ) ft ft in. .
..------rev %"""...., 9IS:5ROTFT s;:.+,}it g,Mt as t+,, x ;l a ti s
OIrrigation OWells>106,000 GPD FROM TO MATERIAL 1 EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' a° ft. be nt'h f T ed j ra w*y
OMonitoring ORecovery ft. ft.
Injection Well:
ft. ft.
OAquifer Recharge 0 Groundwater Remediation.
OAquifer Storage and Recovery OSalinity Barrier `$9 S D/GJU V ANCIOiLappl emote)'' a.,.r S si ••,�,: 3,� a 4K.4 ;:;,�:
t, FROM. . TO . MATERIAL 'EMPLACEMENT METHOD 1
OAquifer Test ❑Stormwater Drainage n• ft. "
OGeothermal(Closed Loop) OTracer 43olt ltittlitit61 'G,.(oftitaili tditipnaTsheetsifnee>•sseii}i K4..N f . Y;,jz;
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,eta)
® it. 30 it. 5 4,.t-
4.Date Well(s)Completed:l'i 't3 Well ID# 3® it .5o ft. 5eivLeis 'ot9i,�
5a.Well Location: �I 0 ft. rap ft. r elite c r c
e,n L1��et.�oll it. ft;
Facility/thvnerName a Eacilin a)it(,if enq)iraht.\ it 1- i �l !1...
ff5 s++P'(i 11= in 2�'Amion(Jc ay5g 1 ft. �`B`/� 2C�T
Physical Address,City,an ip / ft. ft.
vT�u 6p9g n leg ;1.�•ltlr'alow� aa...,i ..ism f^'. 1 r s,,' a
V °.1�g��e �Y i.., .c3-'�• eM`;i�"�°4 aZ ��bl°�ithr"�R�ys1+.:S.�xp�e.,e. ,..
County . Parcel Identification No.(PIN) DWQ/9OQ
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1
• (if well field,one latllong is sufficient). 22.Certification:
6.Is(are)the well(s): dermanent or OTemporary Sign:,.. e of Certified Well Contractor Date
c
By signing this form,Thereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or No ISA NCAC 02C.0100 or ISA NCAC 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#2l remarks section or on the back of this form.
23.Site diagram or additional well details:
$.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.
0 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I 0 (ft.
For multiple wells list all depths if different(example-3®200•and 2®100) (ft.) I
Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: I° (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-16I7
A.-Borehole diameter:
' (in.) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC`27699-1636
12.Well construction method:. a f it r a(Y 24r.Fnr Water Rnnnly and arum-T,nnn f pnthermal Refium Wells:Cony to the
tie,auger,rotary,came,au•ect push,etc.) / county environmental health department of the county where installed
FOR WATER SUPPLY'WELLS ONLY: I
a��,y p 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) O•V Method of test: ki 10 a Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: in4..PI Amount: f -,�4
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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