GW1-2022-01948_Well Construction - GW1_20220224

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WELL CCONSTRUCTION RECORD(GW-I) For internal Use Only: E
1.Well Contractor Information:
Well oruractorName FROM TO DESCRiPTEON
C
A ° 2-0ft. R.
NC We►1 Comractor Certification Number
f al.0. ;FROM ro DIAMETBit Tmcx>vsss MAT>,nrn
° �tmg
Company Name u
2.Well Construction Permit#: W �'�nil - o] 1 mom To nlAMsrEx PHICKNE 11L►TERIAL
IM all Wficable well muftedon permits 0-WC.County.State,Variance,etc.)
3.Well Use(cheek well use):
Water Supply Well:
FROM TO I DLAMM gt,OTgIZg ..THICKNBS.9 ..-TIIOAL+<•-
❑Agdcaltural DMunicipal/Public _ --- - -- -
m odwimal(HeatinglCooling Supply) --ResiNtial Water supply(single) — g, in.
OlndushWCommerciai OResiden tial Water Supply(shared) *.
Dirriegon OWells>100,000 GPD FROM To TSRIALt FbtPLaC$i►fENt OD&AM UNT
Non-Water Supply Wen; ft 0 ft evt b t 4&• &
C1Monitorin 011ecovery m ft.
ectlen • ft
DAgwfer Recharge OGroundwater Retnediation _..
OAgaifor Storage sand Recovery OSslinity Barrier FROM I To Mn o
OAquifer Teat OStotmwater Drainage ft. ft
ORVerimemal Technology OSubsidence Control ft• ft•
ONermal(Closed Loop) QTtaeer
OGeothamal eatin Coolie Rehire ❑Other under421 Rematim FROM I TO DES ON(COW,haftem eWtisoett etc.)
4.Date Well(s)Completed: `a - a Well ID# g Z o it: 1`)D nr.
5%Wen Location: - .
l oo dy n f'� n. rt.
Facility/ Name Facility W#(if applicable) ft ft.
al��1 Wtn�t� �v�nr rn r� . 2ebulor�. arc
-al5`t1 ft. ft.Pbyatcal Address,City,and Zip
T � t o
01ob4 b153
Co�� Parcel Identification No.(PIN)
Sb.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification: ')
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Date6.Is(are)the weii(s): opermauent or OTemporary sigaeaue of ed well onasotor `
By signing this form,I hereby certVy that the:,w fl(s)was(were)constructed in accordance with
7.Is this a repair to an existing weQ: OYes or 24o
15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Wen Construction Standard+and that a copy
(f this is a repair,fill out Anonm welt construction information and explain the nature ofthe ofth&record her been provided to the well owner.
repair under#21 remarb section or on the back of ftform.
23.Site diagram or additional well details:
8.For GeoprobeMPT 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'So Over'in Remmks Box).You may also ouch additional pages ifnecessaty.
drilled:, U.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: y� (R') Submit this GW-1 within 30 days of Well completion per the following:
For multiple w1k list an depths rdohrent(example-3@200'and 2(RVj
24s. For All Wells: Original formIto Division of Water Resources (DWRI
10.Static water level below top of cesin8� (R-) Irtformatioa P`-' Pmewing Unit,1617 MSC,Raleigh,NC 27699-1617
(f uwsr level is alcove casing,use"+"
24b.For bdection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: i t' ay 24c.For Water Su and en-Loo Geothermal Return Wells:Copy to the
(La auger,rotary,cable,direct puah,etc) cou n f-envtmnmetl mom' s
4
talled
FOR WATER SUPPLY WELLS ONLY: Z4d.For Water Wells Droducitna over 100.000 GPD:Copy to DWR,CCPCUA
1 ��� Pit ,NC 27699-1b11
13a.Yield(gpm) Method of test• �0
13b.Disinfection type: Amount: ��• {
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Form GW.l North Carolina Department of Emiroramentai Quality-Division of Water Resources Revised 6-6.2019