GW1-2023-00690_Well Construction - GW1_20230113

WELL CONSTRUCTION RECO GW-1 For.Internal Use,Only:
1.Well Con ctor•Infor' lion: �� •
14.WATER ZONES
Well Contrac rName 1 ,,}� FROM TO I DESCRIPTION
Yaot
a J,r n F ft ft
NC Well Contractor Certification Number JA IV +;9� .
fy'J� y' e �n�� J 15.OUTER CASING for multi-cased wells OR LINER rf a Gable
Q�1 Lt FROM TQ DIAMETER THICIQVESS MATERIAL
Company Name ft ft in
r 7 � 1.'1",; 16.INNER CASING OR TUBING eothermal closed-Too
2.Well Construction Permit#: )`} �' FROM TO DIAMETER TMcmiESS MATERIAL
D 55�5 �,l,l., .;::
List all applicable well construction permits 0.e.IIIC,County,State,Variance,etaJ �- ft 3 1ft $�,� in. `j i
3.Well Use(check well use): ft ft in
.+
Water Supply Well: V.SCREEN
❑A cultural FROM TO DIAMETER SLOTSME 7MC1QVFSS MATERIAL
gn ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft ft in'
❑Industrial/Commercial ❑Residential'Water Supply(shared)
18.GROUT
OIrrigation ❑Wells>100,000 GPD FROM TO I MATERIAL I EMFLACEMENTmrmOD&AMOUNT
Non-Water Supply Well: O ft ft �y��-
❑Monitoring ❑Recave s {
Injection Well: ry ft j. .
❑Aquifer Recharge ' ❑Groundwater Remediation ft ft
❑Aquifer Storage and Recovery ❑Sal FROM
Barrier F D/GRAVEL PACK if applicable
FROM TO MATERIAL .EMPLACEMENTMMOD
❑Aquifer Test ❑StormwaterDrainage ft. ft
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attnch'additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO I DESCRIPTION color,hnrdnea sotVrock type.grain size,eta
ft ft
4.Date Well(s)Completed: :n �✓' Well ID# ft ft
5a.Well Location: 1 ft a 0—Lit
fc�aTP_ �rj� � �✓ ft
F so i 1 i ty/0 w n e A ame Facility ID#(if applicable) ft ft i
r � .„ft ft J 6 b
Physics Address,City,and Zip ft ft
21.REMARKS f
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
6.Is(are)the well(s): etermanent' or ❑Temporary T�� ) Stgatur6 o£Certifie*YWell Contractor Date
�
t/ By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or M-No 15A NCAC 01C:0100 or'15A NCAC 02C.0200 Well CPnstrucnon Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#11 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
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 necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: a (ft)
For multiple wells list all depths ijdrfferent(example-3Q200'and 2ca 100� Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: �� (ft) 24a•.For All Wells: Original form to Division of Water Resources (DWR),
lfwater level is above casin&;use"+' Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
24b.For Injection Wells:Co t
11.Borehole diameter: t� /8 .(in,) Copy o DWI;,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Wcll,rotary,cable,direct push etc.)construction method:
(i.e.sage _ D ant An,, 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 produciner over 100 000 GPD Co to D
13a.Yield(gpm) Method of test: -1.,� Petmlt Program,1611 MSC,Raleigh,NC 27699-1611 Copy 4 CCPCUA
13b.Disinfection type: ^ Amount: 9 hi
Form GW-1 North Carolina Department of Eavummmental Quality-Division of Water Resources. Revised 6-6-2018