GW1-2023-00361_Well Construction - GW1_20230103

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1,Well Contractor Information: ,
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Well r Confracto ame FROM TO DESCRIPTION
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NC Well Contractor Certification umber
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ft. ft. I !Company Name in.
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2.Well Construction Permit#: 1 " FROM TO DUMETER THICKNESS MATERIAL
List all applicable well construction permi�IC,Counny,State,Varl�i�e.eta) ft. 0ft in
3.Well Use(check well use): ft. ft. in•
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Water Supply Well: FROM I TO I DIAMETER 1 SLOTSIZE 1 THICKNESS I MATERIAL
❑Agricultural ❑Vimicipal/Public. ft. Iit. Iq•_.
❑Geothermal(Heating/Cooling Supply) IUResidential Water Supply(single) ft, ft.
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Irri ation, ❑Wells>100,000 GPD FROM TO MAW—RL44, EMPLACEMENTMETHO &AMOUNT
Non=Water Supply Well: 6
ft. ft
❑Monitoring ❑Recovery ft. ft.
Injection Well:
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❑Aquifer Recharge ❑Groundwater Remediation
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❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIALI EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage "
❑Experimental Technology ❑Subsidence Control ft. •
❑Geothermal(Closed Loop) ❑Tracer .30'tiA1LTl+iGtf ttac7i'addrdoitisheees'ifreeessd" "; .;. � ' a
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,sailtrack type,Sn!n size eta
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4.Date Well(s)Completed:L� Well ID# 10 114, ft. it
ft. ft.
5a(Yell f ocation:l d! -
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acility/Ow ft.
ner Name Facility16#(ifap icable)
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Physical /)dd�rless,C' ,and Zip ft ft Frnr.. ,` llrs
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County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
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6.Is(are)the well(s): $4rmanent or ❑Temporary ign of Certified a,,rrotCractor Da
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1 B signing this form,I h r,1by certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or V4 A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and ezplain 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:
o rn, nr .. l,_mum "­A_r,. .,re +ho..,,,i wane 1,-�.,;.rt fl-.�ar,a You may use the back of this page to provide additional well construction info
construe n,only I GW-1 is needed. Indicate TOTAL NUMBER of wells laaa-See wer in FcemarKs nox)•I Vwmay aiso auacn atiuttiunai pdgcs'u nccoaadiy.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 0 0 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Qa 200'and 2@100)
24a. For All Wells: Original fo'mi to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617'iMSC,Raleigh,NC 27699-1617
If water•level is above casing use"+' ;
n 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC.27699-1636
12.Well construction method: Y r 0±9 t111 y 24c.For Water Supply and O eri I-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) couhty environmental health department 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(gem) Method of test:
d Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount: 412
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Revised 6-6-2018
Form GW-1 North Carolina Department ofEnviromnental Quality-Division of Water Resourc I I
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