GW1-2023-00563_Well Construction - GW1_20230104

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WELL CONSTRUCTION RECO (GW-1) For Internal Use Only:
1.Well Coidractor•Information: I .
'
•14.WATER ZONES
Well ContractorName FROM TO DESCRIPTION
3,Fo ft
T ft. 7 ft.
NC Well ContractoY Certification Number IS.OUTER CASING for multi-cased wells OR LINER if applicable)
��zza FROM TO DLAMETER THICIINFSS MATERIAL
L ft. tY. is
Company Name
/O�� a 16.INNER CASING OR TUBING t eothermat closed-loon)
2.Well Construction Permit#:_ {� J PYR
TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permlis(l.e.UIC,Colm%State,Variance,elm) (�,3 ft �(7 e, 'An. L lC t LPi�
3.Well-Use(check well use): ft -in. !I
L
Water Supply Well: EN
TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft in❑Geothermal(Heating/Cooling Supply) - •Residential Water Supply(single) ft
❑lndustrial/Commercial ❑Residential•Water Supply(shared) IS.GROUT
❑Itrigaticn ❑Wells>100000GPD FROM To MA RiAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 23 ft i�{ 4.
❑Monitoring ❑Recovery ft. ft
Injection Well: r,. �ZYi .v
❑Aquifer Recharge ❑Groundwatee iat� i
❑A uiferStore and ❑Salirii Barrier- 19.SAND/GRAVEL PACK its applicable)
q Recovery ty FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwaterl)rai� t}y Q G' ��� ft. ft
❑Experimental Technology ❑Subsidence Control ; ri,x ft ft.
❑Geothermal(Closed Loop) ❑Tracer 1n(orsIM r^v �V�= :20.DRII LING LOG attach'addi•onal sheetr itnecessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) I FROM To DESCRIPTION color,h rdness soiVrock type,grain size,ate
% ft
4.Date Well(s)Completed:IL—a-.;Z- Well ID# ft. •ft
5a.Well Location: l_ ft. ft
rS GCA q e Ly t C 1, 'MY►.1� ft. ft.
FFacili— 'ity�/0� ace `,��b /� Facility ID#(if applicable) ' ' ft.
c. o T y L1wy-t I Fy rk 1Z J / LZI.t V-t-( ft ft �1
Physical Address,City,and Zip 5 �L ft ft
(� 21.RE117AM.1
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal sufficient) 22.degrees: i
(if well field,one lat/long is Certification•
3h ' ��-f ' L • N BSI ' J 33e
W
Z.
6.Is(are)the well(s):Aermanent or ❑Temporary 2 a o 0/ Signal of Certified-Well Conhabtor Date
a! Bys/gning this foim,I Hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or *0 ISANCAC o1C:oloo or15ANCAC 01C.0100 Well Cpnstructlon Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain lire nature of the of this record has been provided to the well owner.
repair under 01 remarks section or on the back of this fasn.
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 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:
3 h / 24.SUBMITTAL IlVSTRUCTIONS
9.Total well depth below land surface: (J (ft
Formuldple wells list all depths ifd ffereti't(esample-3(n)100'and 1 tQr 1001) Submit this GW 1 within 30 days of well completion per the following:
10.Static water level below top of casing:. 46 (ft) 24a• For All Wells: Original'form to Division of Water Resources (DWR),
If water level is above casing,;use 11+1 Information Processing Unit,1617 MS C,Raleigh,NC 27699-1617
11.Borehole diameter: lJ /IV ,(in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
12.Well construction method: Program,1636 MSC,Ralcigh,l NC 27699-1636
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells prod Icine over 100 000 GPD Copylta DWR,CCPCUA
13a.Yield(gpm) Method of test: Perrnrt Program,1611 MSC,Raleigh;NC 27699-1611
- _ Sti
13b.Disinfection type: H I Amount