GW1-2023-00564_Well Construction - GW1_20230104

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WELL CONSTRUCTION RECO (GW-I) al Use Only:
1.Well Co ' actor Inf matio
14.WATER ZONES f•
WrIlConAtorNac FROM To I DESCRIPTION
fL
ft. ft
NC Well Contractor Certification N/u�m�b�er{� 15.OUTER CASING for multi-cased wells OR LINER rf a linble
I&Armin ckr-' 6 W r" �•� FROM TO DIAMETER TSICIINFSS MATERLtL
ft. fG in.
Company Name
J ' 16.INNER CASING OR TUBING eothermal doged-loo
2.Well Construction Permit#:_ ( FROM To DIAMETER TaICENEss I MATERIAL
List all applicable well construction permits(Le.UIG Corny,State,Variance,eta) fL 3 ft 57 in. 1 YfI
3.Well Use(checkwell use): ft ft in.
Water Supply Well: 47,SCREEN
FROM rffl�D!�7E�rS�R SLOTSIZE THICICNFSS UtATLrRIAL❑Agricultural ❑MunicipaliPublic ft❑Geothermal eatin Coolin Su 1 idential water S I sm e
� B/ g PP Y) uPP Y( • P� ) � I �.
❑ladustrial/Commercial esrdential•water Supply(shared) 18.GROUT
❑Irri lion bwens>100000-GPD. FROM - To - MATMMQ EMPIAC METHOD&AMOUNT
Non-Water Supply Well: ft ft_ J�Y {
❑Monitoring ❑Recove
rY' Injection Well: � ft ft.
r ttl
•
❑Aquifer Recharge ❑GroundwatdrRemediation it ft
❑Aquifer Storage and Recovery []Salinity Barrier , 1199.LAArm/GRA LPACK rcOM To, rable
EMPLACEMENT METHOD
OAquiferTest ❑StormwaterDrainage ft ft
❑ExperinentalTehnoloy' ❑Sbsid neeeh f ft
❑C oT ` I.
,
qotkermal(Closed Loop)
OTracer
'20.DRILLINGLOG fgttnch,addiliomlsheetsifnecrssa
❑Geothermal(Heating/Cooling Return) ❑Other a la' e`2LR*S) FROM To DESCRzp1LON rotor hnrdaess soHLE .io; etc
ft ft
4.Date Well Completed: 1 9�ZZ Well ID# � rry 3 ' J ft fe l•
59.Well Location: lr (3!!:�'��L'' ft ft
-5!-, t 011 l a-r�Yt•✓ ft ft ;e hci✓L-
Facility/04ner Name Facility ID#(if applicable) ft fE
1 a C'k; -e 23!�AC ni s L ,., -W. 1 e ft Zia i� �i
PhysrcalAddcess,City,,andZiP ) ftv ft
Ik-
1 V 2L REMARKS f
Coun
Pareol Identification No.(PIN)
f1
I.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one IaNlong is sufficient) 22.Certification-
is
i
-" 6.Is(are),the well(s)d • eLrYP cmanent or OTemporary Si6oaturi of!"ertified ell Contractor Date.
� Bysigning this form,I Hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: Yes or M590 ISANCAC 02C:0100 or
❑ 25ANCAC 02C.0200 Well Construction Standards and that a copy
Ifrhis is a repalr,fill Outbraxm well construction information and explain the nature of the of this recordhas beenprovidedto the well owner.
repair under#21 remarks section or on the back ofthisform.
23.Site'diagram or additional well details:
S.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 NUMBBR of wells (add'See Over,in Rdmarks Boz).,You may also attach additional Q
drilled: . . pages if necessary.
t 24.SUBMITTAL INSTRUCTIONS '
•9:'Total well depth below land surface: J�fI (ft) •
For multiple wells list all depths ifd1geredi(cramp1_-3@200'and 2ta 100) Submit this GW-1 within 3016' of well completion per the following:
10.Static water level below top of casing. a 24a• For All Wells: Original form to Division of Water Resources (DWR),
!f water level is above eas►ng,;vse (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: G�b (�•) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(TUC)
Program,1636Raleigh,NC 27699-1636
12.Well construction method: /C d a.L,,—n'l'�
(i,e auge,rotary,cable,dicectpush,etc) 24a For Water Supply and ODen-Loop Geothermal Return Wells Copy to the
county envlzonmental health department of the county where Installed
FOR WATER SUPPLY WELLS ONLY:.
24d.For Water Wells prodncin�over 100 000 GPD Copytito DWR,CCPCUA
13a.Yield(gpm) PelmrtProgram,1611 MSC,Rafe Method of test; i I rgh-,NC 27699-1611
t S'
13b.Disinfection type: Amount: 1'✓
'Form GW-1
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