GW1-2023-00566_Well Construction - GW1_20230104

WELL CONSTRUCTION RECO GW-1 Far Internal Use Only:
1.Well Contra�idigrmation, -�
• •14.WATER ZONES I i
Well ContractorName FROM TO I DFSCREMON
ft. Ift!
ft. ifti 1.
NC Well Contractor Certification Number 15.OUTER CASING For multi-cased wells OR LINER rf a licable
FROM TO DIAMETER THICKNESS MATERIAL -
_ l�f� ft. ft in.
Company Name • '
YN 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: s FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e UIC,County,State,Variance,etc.) ft . t't in.
3.Welt Use(check well use): ` it ft in
Water Supply Well: 7:SCREEN ,
FROM TO DMETER SLOT SIZE THICKNESS MATER AL
❑Agricultural ❑M /Public IAft ft' in. -
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft in.,
❑Industrial/Commercial ❑Residential'Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUP
Non-Water Supply Well: Q ft Z3 ft iT
❑Monitoring ❑Recovery ft ft
Injection Well:
ft ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK rf a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD. _
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology El Subsidence Control' ft ft
❑Geothermal(Closed Loop) ❑Tracer '20.DRILLING LOG attach'additional sheets if neces3a
Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPriON color,hardness,sciVrotk a is ' etc
❑
- _ ft 'ft
4.Date Well(s)Completed: Z� �LZ Well ID#, ft to TCA 011
5a.Well Location: ft. ft
ft ft
(, „6-
`a
• Facility/Own Name FacilityID#(if a ft pplicable) ' ' ft: L-lk-4 -5 e 4-„_d
'
hill �� fir. � /kl'�e ALA&11- -"ft � AN G 2023
Pal s Ad ,City,and Zip Q ft! ;ft
21.REMARKS,/ I r ;R".A t'vi1 i Wlllai r-"rc U-A
v e' ti:f4
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell 5eld,one]aVlong is sufficient) 22.Certifrcati' I
3 ' S N w �
6.Is(are)the well(s):elfermanent or ❑Temporary �]SD f Signature'bfCertifiedWellConractor Date
I By signing this form,I hereby certify that the well(s)was(were)constructed in accordance w
7.Is this a repair to an existing well: ❑Yes or � 15A NCAC 02C:0100 or'15A NCAC 02C.0200 Well Construction Standards and that to cc
If this is a repair,fill out known wen construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarla section or on the back of this farm.
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 infc
construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Rdniarks Box).You may also attach additional pages if necess$I
drilled: 24.SUBMTITAL INSTRUCTIONS
9.Total well depth below land surface: 2-0 ft
For multiple wells list all depths ifdifferat(example-3 c@t 200'and 2 rQi 100� ( ) Submit this GW 1 within 30 days of well completion per the following:.. ._
I
j d Information Processin24a. For All Wells: Original form to Division of Water Resources{DWI
10.Static water level below top of casing: (ft)
g Unit,1617 MSC,Raleigh,NC 27699-1617
#"water level is above casitr,vse"I 1. ` )
'
11.Borehole diameter: t� �T ,(in•) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUI
LL Program,1636 MSC,i Weigh,NC 27699-1636
12.Welt construction method: bT a "i _ 24c.For Water Suuply and Open-Loop Geothermal Return Wells Copy to 1
(i.e.auger,rotary,cable,direct push eta.) �- county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100 000 GPD:Copytto DWR;CCPCIJ
Permit Program,1611 MSC,Raleigh;NC 27699-161 I 1 ti
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
. II
Form GW-1 North Carolina Department ofHavironmental Quality-Division of Water Resources r:-4-4 c-A_'in