GW1-2022-10677_Well Construction - GW1_20221205

WELL.00NSIRUCTIONRECO GW-1
For Internal Use Only:
1.Well Coritra .Information,
? .3
Well Coa6cactorName 14.WATER TO
/ • fa, f,; + FROM TO DESCRDTlOtt
ft. ft
NC Well Contactor Certificatioa Number rc v
ITS.OUTER CASING(for' uld-cased welts OR LINER Of a livable
?ISO
j��
DIAMETER 7MCKN=1 1 MATERIAL
Company Name , -y S' & ft
n FROM ER CASING OR TUBING othermaldoffed-loo
2.Well Construction Permit#: -Cf FROM TO DIAMETER TSICKNEss MATEPIAL
List aU applicable well eonsrruedon pEQU&I.OZe
17IG Cormry,State,Vattanee,ete) - ! fG O' tt' in.
71-1 iCt^
3.WellUse(checkwell use): ft ft -in.
Water Supply Well: 7.SCREEN
OAgriculturaj IRtOM TO DIAMETER SLOTS TffiCIQVESS MATERLtL
❑Municipal/Public & !t in
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single)
ft ft i' in.'
❑IndustriaUCommercial ❑Residential'Water Supply(shared)
13IrriRation I8.GROUT
❑Wells>100,000 GPD FROM TO MATM AL En>pLACEhiEttrMETaoD�AMornvr
Non-Water Supply Well: . ft 2 ft ,�
❑Monitoring - - ❑Recovery - - - ' s
Injection Well: ft
❑AquiferRecharge ❑Groundwater Remediation ft ft
❑Aquifer Storage and Recovery ❑Salinity Barrier �o�/GRTo LPAQc a likable
EMPrdCEMENr METHOD
❑Aquifer Test ❑StormwaterDrainage ft ft
❑Experimental Technology ❑Subsidence Control; ft tZ
i•
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach'adcu'onal sheets if necessa
❑Geothermal(PIeating/CoolingReturn) ❑Other( lain under#21Remarks) FROM TO .'DES�nONcotor,herdnmsoiVmck to ee�
ft ft'
4.Date Well(s).Completed: J '2^I LZ Well ID# it tt
Sa.Well Location; nn ft ft ,
M'a 1r-%t� rit ( sUUt,'tn • ft.
Facility/Owner Name Facility ID#(if applicable) - ft ft
l (o T�� a r �n. , d -ft ft -
Physical Addrws,City,and Zip ft '
,/ ft .
S Lk Y`I-V ) 21.REMARKS.(
County Pascal Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: !'
(ifwall field,one latAong is sufficient) i
J �, 22.Certification: ,
N Rt ;'
- �' �v %Z- 2.2-L-
6.Is(are)the well(s): ermanent or ❑Temporary Signature ofCerr ifiedwell Contractor Data
7.Is this a repair to an existingwell: ❑Yes or Bysigning thlsjoim,I hereby certify that the wells)was(were)conshucted in accordance with
ISA NCAC 02C:O100 or ISANCAC 02C.0200 Well Cvnstruetion Standards and that a copy
Ijthls is a repair,fill out known well construction information A1.1.the nature of the of this record has beenprovided to the well owner.
'repair under#21 remarks section or on the backofthisform
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
conshvetion,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.drilled:
24.SUBMITTAL INSTRUCTIONS '
9.Total well depth below land surface: co-A6 '
For mult/ple wells list all depths ijdI(example-3(n)22/00'and 2©100) (f b) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top okcasing. l0 V (ft) 24a•-For i Wells: Orig i al form to Division of Water Resources (DWR),'.
ljwarer level is above eosin&;nse"+" Information Processing Unit,�1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter. G (m,) 24b.For Infection Wells:Copy to DWI;,Underground Injection Control-(IUC)
Program, MSC,Raleigh,NC 27699-1636.
12.Well construction method: l<D T e'3 Vvt ,� - -
(i.e.auger,rotaM cable,direct push,etc.) �� 24c.For Water Suably and�Ouen-Loon Geothermal Return Wells Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells Drodncine over 100 000 GPD Copy ito DWI;,CCPCUA
13a.Yield m ^ _ _ Pemut Program,1611 MSC,Rate(gp ) Method of testi rgh;NC 27699-1611
• _ tit
13b.Disinfection type: Amount-
Form GW-l North Carolina Department ofEovimumental Quality-Division ofWaterltesources
i.