GW1--04228_Well Construction - GW1_20240719

..a.,1,1u t,4!111.7 a IVIJ V i iUlr i ralL.Unu l t s W-11 For Internal Use Only:
1.Well Con ctor Information'
7\
14.
/� �.kOS1/)v)/C1-3 v FROM WATER Tom DESCRIPTIONwe Conuactar Name c0 it. 'Z/5-ft' 4:
N 11ContraMor!)C ttficatiZve,1
on Number t� 7yy.��� 15.OUTER CASING(for mnitltated wells)OR LINER(Sap liable)
n- f^n/ / !/ t�/1� 6,,
,FROM/ TO O1MnTlli TTHICIQj�fEESSSMAJTERIIAL
Compa�Name / T�Z it
Z� ft. in. -Y�iJ 7t I/ e:„.
` �/ / 16.INNER CASING OR TUBING tuothermaICclywed-loop)
2.Well Construction Permit#:Pw U'226 /4D O 3 3 FROM To mAma:rI:R irtrctaxEss MATERIAL-
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
• 3.Well Use(cheek well use): ft. fL In.
Water Supply Well: 17'SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 2./�, ft' In. 2.0 /}
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) IL R a. l S� Yv �uG
❑Industrial/Commencial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO ES TEHLIL IPLACE' METHODAMOUNT
Non-Water Supply Well: ft. � IL� f 4 , 2d °CIO t )3
❑Monitoring ❑Recovery ft. f
Injection Well:
ft. I It.
❑Aquifer Recharge ❑Groundwater Rem ediation 19.SAND/GRAVEL PACK inapplicable)
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM �TO`� MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage L It. GOB ft.7b' ,to/P,C- j, yf,, CTCG e..__7`
❑Experimental Technology OSubsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheet,if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DES CRIPiTox(cola r,n■rarer,.omroel�type, artze eta)
fL R.
4.Date Well(s)Completed: / �ZY Well ID# fL ft.
ft. ft.
Sa.Well Location:
mere. Mg Ole kA fL ft �. .- '•
It-1 ,
•
Facility/Owner Name Facility UM(if applicable) -
fL ft. 1 `
il
/ 21 r(u /�S ( 7 1'/M-f.C7i7GI� I -/ ft. fL - ✓ zoZ`F
Pip1 A drus,�Ciity,and Zip /1 (L fL f y -
/ / i ` ° q 21.REMARKS Cri.
Ccumty Parcel IdeJificatien No.(PIN) r l
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(Mfwc11 field,one!at/Iong stacker)
is stcieer) 6 22.Certifica n: /
- `�mod,3��/ N ---? 7 2 CD t 3 zaw r------- S"ZY/27 _
6.Is(are)the well or s): ermanent or ❑Tempary Si rtified wet ntrocto
-
signing this form,I hereby certify Mai the well(s)was(were)constructed In accordance with
7.Is this a repair to en existing well: ❑Yes or e ISA NCAC 02C.0100 or I5A NCAC 02C.0100 Well Construction Standards and that a copy
If this is a repair,Aril 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 farm. 23.Site diagram or additional well details:
8.For Ceaprobe/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-I is needed. Indicate TOTAL NUMBER of wells (add Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / t 2 -).0 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For muldple wells list all depths iifddereru(example-3Q200'arrnrd11Q100)
0'
10.Static water level below top of casing: -!cJ (fL) 24a. For All Wells: Original form to Division of Water Resources (DWR), '
If enter level is above casing we '+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: // (In.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
/ Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ()/Lj t.n714/. 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.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
13a.Yield(gpm) Method of test: /4't)/L Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: / / -4- Amount: ( t
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6-2011
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