GW1-2023-00484_Well Construction - GW1_20230104

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Ll qi o P,0 Je)
Well Contractor Name ��. FROM TO DESCRIPTION
ft.� l' ft.
A � �ft ft.
NC Weli Contract r Certific tion Nl nber
15...OUTER:GA51NIVformulfi-case" we11s;ORLINER ifa lica6le ,, ;; `�
FROM TO DIAMETER THICKNESS MATERL►L
0 ft 0 ft to
Company Name 7 `S6,INiVER CASING OR TUSIIYG `bthermsl closed 1"o..d' ,
2.Well Construction Permit#: W V 7S 1 6 1 ��r FROM TO DIAMETER THICKNESS MATERIAL
Q
List all applicable well construction permits(i.e.UIC,Coumy,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
FROM TO DLAMETER SLOT SIZE I THICKNESS MATERL L
❑Agricultural ❑ icipal/Public ft. ft. !no
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18 GRt)I)1
� s
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT-
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
ft, ft.
❑Aquifer Recharge ❑Groundwater Remediation
„19�AIYp/GRAELPAOK';tf a 'livable s, hr t .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLAC&NMNTMETHOD
❑Aquifer.Test ❑StormwaterDrainage fL %
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20<DRILLTNGI'OG attach additonalsheets;tfztecessar•`;`-'
FROM TO DESCRIPTION(color hardness solUrock e,grain size,etc.
❑Geothermal(Heating/Cooling Return) El Other(explain under#21 Remarks)
(Q� ft. 19 rt. l�0 5 61
4.Date Well(s)Completed: /10 2� Well ID# 0 Z 1J ft. a Cal
ft.
5a.We Location: 1 b® ft rt D it. a ( & 0&
I n s IO W ft. ft. < J
-
acility/Owner Name Facility ID#(if applic ble) ft. ft.
a,O
�
Physical Address,City,and Zip ft. ft. i = Z023
�0 3 1 5 p z ,ziEMAlucs n r f; - �:
v i l)n;a
Lm
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. r lcation:
i
N W
6.Is(are)the well(s): ipermanent or ❑Temporary re of Ce ified We on actor ate
ng this form,the eby certify that the wells)was(wer•e)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out bmown 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:
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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necdssary.
drilled: 24.SUBMITTAL INSTRUCTI6NS
9.Total well depth below land surface: l �® (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100')
10.Static water level below top of casing: 6 (ft.) 24a. For All Wells:- Original form to Division of Water Resources (DWR),
"+'�
Information Processing Unit,1611 MSC,Raleigh,NC 27699-1617
Ijwater level is above casing,use
lfBorehole diameter: (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11. Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Ir e-fg ar 24c.For Water Supply and Open-Loop 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 producin I over 100,000 GPD:Copy to DWR,CCPCUA
I Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: i
z Vb
13b.Disinfection type: � Amount: � I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201 B