GW1-2023-00359_Well Construction - GW1_20230103

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:.
1.Well Contractor Information:
4) V4 CJUfi► P(�J.)`�. k, 4.,UWAfiEIZ":`�it5 11t3 i`'S M ...'� 11%
Well Contractor Name FROM TO DESCRIPTION
T ft. ft. ( M
ft it.
NC Well Contractor Certification Number 1 n ;X�r3p iEg<C jSlisj(,(!ol<riiUltrea5e sYeils DIt. R as pllealrl
J FROM- ' TO.' t)LUNrtiku,l 77/rt:KYESS MATERL1L
9� ft. ft r .I m.
Coin any Name a.
•��2.Well Construction Permit#: � I �:]b:�INPiI;ILEt1Y fst..%Fl�t'l'13Xi1�1Gr euthe>:dial�luse�.la.,•..u... . r.:..�'nl.. ,�.,.;_ ��s�.
N a cr.". FROM I TO DIAMETER THICKNESS TEAIAI
List all applicable well construction permits(i,e.UIC.Coum%State, PQH etc.) 0ft. !�' b ft. in. v
3.Well Use(check well use): ft. ft. in.
'ri7�5CILEEI�
Water,Supply Well:
FROM TO DIAMETER, SLOTSIZE THICKNESS I MATERIAL
CIA *cultural icipal/Public ln:i
❑GeothermaljHeatingil oo]Ing'Supply) L+Jitestdenhal Water Supply(single) — --n,:: -" ft.
sni'
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Irri ation, ❑Wells>100,000 GPD FROM TO MA EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft R, r
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft ft
❑Aquifer Recharge ❑GroundwaterRemediation z
29?S`AND/GFlAYEL�AG'lC; t llcalle_ .1 .:
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stotmwater.Drainage 1% r }
❑Experimental Technology ❑Subsidence Control ft. ft. l I
[]Geothermal(Closed Loop) ❑Tracer r'h0 3IIIDLLNG tE7iD attaeli additroiia7 sheetB,f iec�ss _ a : ,. t .w
❑Geothermal(Heating/Cooling Return ❑Other(explain under#21 Remarks) FROM To DES RIPTION(color,hardness soiVrack a ruin size etc
-� 0 't- Z. m
4.Date Well(s)Completed: 1 Well ID# 0 1 a• ft 0 ft. G
5.egLocation: 30 f' 0k eb
FacifiVOwner Name Facility ID#('f applicable) 1 K.
31 ft. ft 1 v
Phyyyyy"/������i,.� AddreP,Fity,andZip ft �r fell r'C^rw�2rSrF�,�1.livi
v Y`fJl. ._. +•v7 Y.�. e� �+ .. � �--�..Y f �:'s gtrr 4. l :r s:.
.'If !1/Al / pl.. .'x�i• 4 .'r. :u.Y �. .:a,f s•. ..p,: .,�•..c:+;..r ,'.t��s,. _,.'�.
County P el Identification No.(PIN) n ,a hAf
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: b
/ N W
6.Is(are)the well(s): 4Permanent or ❑Temporary Si e ofurtifiem Contractor Date
signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or io 15A NCAC 02C,0100 or 1 SA 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 of this 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:
R For GeonrobeiDPT or f Inseli.T_,nnn Geothermal Wells having tirP Farne You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is deeded. Indicate TOTAL NUMBER of wells Cauu`OW V V ci iu ncuimisz nunl w may'a`wc aiuscii auuiiiuuai pagc�'ii ncccx�riiy..
drilled: `f 24.SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: b (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dyerent(example-3@200'and 2@100)
24a. For All Wells: Original foim to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,16I7 MSC,Raleigh,NC 27699-1617
Iftvater•level is above casing,use"+"
24b.For Infection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: ffii ,*((n) A w Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: W��:. - 24c.For Water SUP41 and Open Loo 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 lover 100,000 GPD: Copy to DWR,CCPCUA
( Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) a'- Method of test: 10 UJ
13b.Disinfection type: Amount: f
Form GW=1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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