GW1-2023-00543_Well Construction - GW1_20230104

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
U-Q 5 d ro 0 e/ 14 WATER.ZOIVES' „ .. izw
Well Contractor Name FROM TO DESCRIPTION
a a�� yt rt. g ft. 5�
NC Well Contractor Certification Number 15 OU PER C4STNG rot;multi"Wins),bA'Lll!iER'if a Lcalle a
py I e I u fl �Li FROM TO DIAMETER THICKNESS MATERIAL
ul.fff��� lV�' O ft 4 ft m C
Company Name . ,
I .,16INNER'CASING OR Ti3RING ebthermalrclased loo" :_ ,> ,
2.Well Construction Permit#: t,�+o D d d 33 ` FROM TO DIAMETER THICINESS MATERIAL
List all applicable well construction permits fl.e.UIC,Coup!),,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): it. ft. in.
Water Supply Well: .17.SCREEN .`� � .,,�.;,. ,.•� ,..>: :,.:: . ,,:
FROM TO I DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ Ictpal/Public ft. it, in.
❑Geothermal(Heating/Cooling Supply) 0JAesidential.Water Supply(single) ft. ft. in.
❑Industrial/Commercial []Residential Water Supply(shared) „lg Gi20�(IT . y
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAI, EMPLACEMENT METHOD&AMOUNT t
Non-Water Supply Well: ft. % h r
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fr tt
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) []Tracer 20.DIILT INGf OG attacli'additenai sheefs'ifnecessa' ''_
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTI N color,hardness,soll/rack type,grain size,etc.
p ft. p rt. a n
4.Date Well(s)Completed: 0 Well ID# N a 0 ft. 00 fit. r z h , C ,r6 L
5a.Well
[Location: ft. ft.
ply s H
Facility/Owner Name Facility ID#(if applicable) It, ft.
3O �uI lA� a 5 fc. ft. JAN 0 G RID
Phrsial Address,City,and Zip ft ft r t!n 1
.� t,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22. cation:
e N W 6
6.1s(are)the well(s): t$Yermanent or ❑Temporary S' ature of Certified Well actor atve
By signing this form,I hereby certify that the well(s)was(were)constucted 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/mown 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
construct•on,only.1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 400
A) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dierent(example-3@200'and 2@100D 1
10.Static water level below top of casing: (ft.) Information
For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwater level is above casing,use"+'
24b.For Injection Wells: Copy to C)DWR,Underground Injection Control(IU
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: C41 ht r y24c.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 producing over 100,000 GPD: Copy to DWR,CCPCUA
I
13a.Yield(gpm) Method of test: W Permit Program,1611 MSC,Raleigh,NC 27699-1611
I,, I
13b.Disinfection type: 1'1 Amount:A::�
l t
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources, Revised 6-6-2018