GW1-2022-03545_Well Construction - GW1_20220322

L Well Contra/ j
Contractor Information: I
Lc,tn&) /t f,(_C I,� -:14._.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
C i L( /- ZL ft. Z 2
NC Well Contractor Certification Number ft. ft.
^A ///��� n /� 15 OUTER CASING formulti=cased webs OR LINER if a licable
/V S � Po c) i. WC.f 1 G U M(/r FROM TO DIAMETER THICKNESS MATERIAL ,
W (� 1 1 A ( / ft. c
Company Name 3 ft. in,
4 �
16-INNER CASING OR"TUBING: eothermai closed-loo
2.Well Construction Permit#: fitJ — 0S17 Cr�(�..�v2 FROM To DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in,
3.Well Use(check well use): ft.
Water Supply Well: '47:SCREEN"
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OM icipal/Public ft. Qf(ft. L, io,
❑Geothermal(Heating/Cooling Supply) �ffesidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑bTi ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLAC NT METHOD&AMOUNT
Non-Water Supply Well: ft. 2,9 ft.
❑Monitoring ❑Recove
ry ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation [t. ft.
❑Aquifer Storage and Recovery ❑Salini Barrier 19 SAND/GRAVEL PACK(if ai licable
ty FROM TO I MATERIAL EMP EMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ( ft. 641, t, �!m C lJ�r
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer =211.'-DRILLINGLOG attach additionIhi sheetflf.necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soil/rock rain size etc
ft. �. ft. e
4.Date Well(s)Completed: "l> Z Well ID# ft. ft. Cj
5a.Well Location: r G ft. O t t�
To e M- Jor ft. ft. �J
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Q
Physical Address,City,and Zip Al L 7 2 Z ft. ft. MAR
A R _
oJod , 21;'REN ARKS tVIH
County Parcel Identification No.(PIN) I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one fattlong is sufficient) p� t 22.Certification:
3(o.n�U2 N U s� a 7 W e Z
6.Is(are)the well(s): rmanent or ❑Temporary S atur�Certified Well Contractor Date
,,�� By signing this form,l hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or UAD 15A NCAC 02C.0100 or 15A 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 ofthis 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 construction info
construction,only 1 GWPI is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:_ SOS 24.SUBMITTAL INSTRUCTIONS
ft
9.Total well depth below land surface: .
For multiple wells list all depths ifdti ferent(example-3@200'aan-d*2@100') ( ) Submit this GW-1 within 30 days dwell completion per the following:
10.Static water level below top of casing: 2 y (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+ f Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: b (in,) 24b.For Injection Wells:Copy to DWR, Underground Injection Control(IUC)
j� Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method Ili/) k 1
(i.e.auger,rotary,cable,direct push,
tr 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Droducing over 100,000 GPD•Copy to DWR,CCPCUA
13a.Yield(gP m) 76 Method of test No Permit Program, 1611 MSC,Raleigh,iNC 27699-1611
:
13b.Disinfection type: Amount: / L ,J
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