GW1-2023-00358_Well Construction - GW1_20230103

For Internal Use Only:
WELL CONSTRUCTION RECORD (GW-1) r
1.Well Contractor Information:
F„
V rrS.•\
Well Contractor Name FROM TO I DESCRIPTION
�a1 .A it. a to 3 ft• 0 ; m
fL f
NC Well Contractor Certification Number 1 �f r15 OtJT' G1�S21Cs(fnti4lh c99C syells) ?R;T•1NT� (t£Spplfeatiie) ��`
�•• `, [�����1) "��.I� .� :{� yyt_^ '. FRO,�I TO, UtAVIETErx 7'H1CKNMS. MAERIAL
«//��Y it� atC 1 1 i{/ n I ft in VC,
Company Name CI s
l I .:16;.I1!11VRRCASIi��Y31��CTBII�i(T '�uitheKm eloi:ed�ltiu �.s�.�'.r z�.,,��;�,�_.k Y:_
2.Well Construction Permit#: ��� Pa rG FROM TO DL IMETER THICKNESS I MATERIAL.
List all applicable well construction permits 0.e.UIC,County;State,Yai'a 'e,•etc.) 0 ft. ! D ft. q in. V G
3.Well Use(check well use): ;: % ft. in.
d7'v.?S.G P+PI',a.Mv.; n w fa ..sty �F�Nzlu iL4 '��.Z:�r, � �✓��;"�..,��tPt-'s�+dvt,.. ,371a'.
Water.,Supply Well: FROM I TO I DL METER I SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. A. in. .
❑Ueothermal(Hcatm Coolm 5uPPLY) VXesidenttal Water 3uPPlY(single)
in- •
❑lndustrial/Commercial ❑Residential Water Supply(shared)
��On:VRt�r11 t.�i.: ..x':.. �f.._ t'i ...{.•e1 7.:1Y_.,- r',A.:1... .a.�?� �e?i ...l.,r
131r i atiou. ❑Wells>100,000 GPD FROM I TO MATERL4L EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0ft 1p ft• Ka V j
❑Monitoring ❑Recovery
Injection Well:
ft ft.
❑Aquifer Recharge ❑GroundwaterRemediation5
19 SANA/GRACE 3'eTC1S Ifa "11c'aliie �r_.. ,. sy, . Y_
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL I EMPLACEMENTMEMOD
❑Aquifer Test -❑StorrnwaterDrainage
❑Experimental Technology ❑Subsidence Control ft. ft.
i
❑Geothermal(Closed Loop) ❑TracerO:IiTt1 LING" mttacli"eddef16na1.sHeeb;=lfn`ecessa ''t. .. . . r4tf.+:, ,�.;:
❑Geothermal eating/Cooling Return) ❑Other(explain under 421 Remarks) FROM To DESCRIPTION color hardn sotUroek e a size eta
4.Date Well(s)Completed: ' Z` Well ED# �� 15 3 p ft. 300 ft ► (•4,K f
5a.Well Location: it. ft.
n 1 t i ft. ft.
Facility/OwnerName Facility ID#(if applicable) fu' 'Z "'
all ft. ft. JAB o 3 M3
Physical Ad s,City,and Zip ,- tt ft.
LJ.vI� Uv
County Parcel Identification No.(PIN)
5-b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
// N W
6.Is(are)the well(s): 5 Permanent or ❑Temporary Simdf&e of Certified We Con actor Date
J lA
gning this form,I hereby rhfy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: Dyes or &No NCAC 02C.0100 or IS NCAC 02C.0200 Well Construction Standardsand that a copy
Ifthis!s a repairf ll out known well construction information and explain the nature ofthe s record has been provf ed to the well owner.
repair under#21 remarks section or on the back of this farm.
23.Site diagram or additional well details:
R•For Geonrobe.TPT or Closet Loon Geot'IIenmd Wel1C havma the-q 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 -tatitr ann vvni w Ammum nua1:uu Way disu aAacu atieiliiunai pages"ii uccw�ay:
drilled: ( 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 6 (ft.) Submit this GW 1 within 30 days of well completion per the following:
For multiple wells list all depths if di,/ferent(example-3Q200'and 2@1001
�1 24a. For All Wells: Original f Irm to Division of Water Resources (DWR),
' Static water level below top of casing: a A) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells:Copy to
11.Borehole diameter: (in.) , DWR'Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: U,i r ho: � 24c.For Water SuVXly and Open-too Opefi-toop Geothermal Return Wells:Copy to-the
(Le.auger,rotary,cable,direct push,etc.) county environmental health depai I t went 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) 0" Method of test:
Permit Program,1611 MSC,Raleigh:NC 27699-1611
In �
13b.Disinfection type: '` Amount: 2 I Ip
I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018