GW1-2023-00539_Well Construction - GW1_20230104

For Internal Use Only:
WELL CONSTRUCTION RECORD (GW-1)
1.Well Contractor Inform tlon:
e/ L
FROM TO DESCRIPTION
Well-Contractor Name ft.
ft, ft. cn
i
NC Well Contractor be ification Number /� — d5"Glib SINt'= 1oi~Inul(t sa5¢' wells;f1It I T(%(tf a li"cable);x; .,ru"
a 1! F a t
�,ry q � �l ,ten ilia-a�i�auo. innia;i.iau.ft aV ft. 0LJL 6 tni
t t &W1
Company Name lI! 1BR CxlB>Ntl ORy£ Ca "1 dtGermai Grose$-1a" a y §` ,, r�.
2.Well Construction Permit#: FROM I To DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,Counq;State,VaH W O,etc.) ft. ft. in.
3.Well Use(check well use): "*" ft. 1t in.
Water Supply Well: Ri`1A5C1T13I ( 4tiLu>Y T.Fou ,x s,xz,th)r. XUEaiz�r,s✓x dJ3s�:S
FROM TO DIAirIETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft, it.
d '
uveoruermai�tieaungtt.;ooung nTpfy) VKesiaenuai water buppiy tsingie) ft ft. n,
❑Industrial/Cornmercial ❑Residential Water Supply(shared)
131rri ation. ❑Wells>100000GPD FROM I TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft ® n•
- ❑Monitoring ❑Recovery ft. ft.
Injection Well: ,
ft. ft.
[]Aquifer Recharge ❑Groundwater Remediation i
v13s;13rk1�llll' `:GYEI";:�A�`Jf fa.•�llcable ��n .�4it,5:'Y`.�.„i . .iS?;c,.-�?�:"1 'k-�'i;',
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Test uJtormwater Drainage �•
❑Experimental Technology ❑Subsidence Control ft.
n•
❑Geothermal(Closed Loop) []Tracer r30 3iRli LINGEXth htfalclraiT�iddiinl`sheeit:i!neaesea"''.' ri,,,?�,�i.. ;`
❑Geothermal eating/Cooling Return ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardnes soWrock type,grain ft eta
ft. 0 ft a
4.Date Well(s)Completed: Well ID# 0 i z G
Sa.Well Location:
k' ft.
ft. ft. - �'•L ii'L rf��
Facllity/owferName Facility ID#(if applicable) ft. k
4T�_ool n a,,�i—d, . 2t!4JU,IM ft ft. JAN _ Z LJ
Physical Address,City,and Zip R' ft P r
:'�"-�'�,��>.,y'x',�.+:i��
W
Coun Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifvvnil finhi nnn latllnnR is e.+i`firiert) I's
N W J�
6.Is(are)the well(s): 41'ermanent or ❑Temporary Si CertifiecrWell cohacEr Date
signing thisform,I here certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 4o 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
#'this is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis form, 23.Site diagram or additional well details:
8.For Geonrobe/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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (auu'3r.Q W Vr, 11.iicuaaaiaJ"-j)l V.uaay.aiaV a iNr Lww.auulLivuaa yar,,ai uV Vwouiy.
drilled: 1 r 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 For multiple wells list all depths ifdeerent(example-3Q200'and 2@100) (ft) Submit this GW-1 within 30 diys of well completion per the following:
a 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+"
11.Borehole diameter: (fn.) 24b.For Injection Wells: Copy to DWI,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: �� tu-P 24c.For Water Supply and Olien-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installe
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producili glover 100.000 GPD: Copy to DWI,CCPCUA
�-� Pernnt Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) h;o Method of test: VV WW `
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resou Ices Revised 6-6-2018