GW1-2023-00730_Well Construction - GW1_20230113

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: Print orr%h' .
—
1.Well Contractor Information: I
-Chris King WATER ZONES
14. ATE
Well Contractor Name FROM DESCRIPTION
ft.
Am
2080-A -r�
ft. ft.
NC Well Contractor Certification Number JAN 1 2023 ��q 00
IS.OUTER CASING 3LUM rased
.wells Drill, Inc. FROM TO Leased wells)OR 1111AUR ifa licable
ImZe ffiCKNESS
ft. MATE L
Company Name in.
16.INNER CASING OR ING eotherinal d
2.Well Construction Permit#: P FROM TO DMETER THI ESS
List all applicable well construction peimils e.u1c,County;State,Variance,etc.) 0 ft- 4-�o ft16 in.
3.Well Use(check well use): —ft, ft. in.
Water Supply Well: 17.SCREEN
FROM f To WAMETER %ES,S
Agricultural DMunicipal/Public ATERTAL
Geothermal(Heating/Cooling Supply) iWesidential Water Supply(single) & In.
—-----------------;____
ft. I ft. —
Industrial/Commercial Residential Water Supply(shared) E —
Irrigation 18.GROUT
11 Non-Water Supply Well: FROM TO MATERIAL NTiM�fiEHUFFOD&AMOUNT
& .10 & L-
Monitoring fL ln&4pi; )e _.0 I,
Injection Well: ft
Aquifer Recharge oGroundwater Remediation ft. ft.
Aquifer Storage and Recovery Salinity Barrier 19.SAND/GRAVEL PAC
FROM TO MATERIAL EMPLACEMENT ME"FU013
Aquifer Test oStormwater Drainage ft ft
lExperimental Technology OSubsidence Control ft ft
:)Geothermal(Closed Loop)
DTM= 20.DRILLINGLOG attachadditionats If nece
7]Geothermal(H ating(Cooling Return)_0Other(explain under#21 Remarks) FROM TO DESCRIPTION
6 ft
4.Date Well(s)Completed:) -6 712 3 Well ID# .. ft
5a.Well Location-
13L A 17 IQ W
ft. ft.
Facility/Owner Name Facility ED#(ifapplicable) ft. ft.
31�6 pu ,j_0 lizooa ft. ft.
Physical Address,City,and Zip 2_7S -ft- -ft-
_T17RE—MAIR
County
Parcel Idetifi;t-.n No (PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latqong is sufficient) 22.Certificatio-n:
6.Is(are)the well(-IdWer /_Q��66�d
manent or Temporary Signature ofCcrtio Well Con actor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.fs this a repair toan existing well: [DYes or To with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well construction Standards and that a
ffthis is a repair,fill out known well construction information and euplain the nature of the copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthisforin.
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 site details or well
construction,only I GW-I is needed. Indicate TOTAL NUMBER of'wells construction details. You May also attach additional pages if necessary.
drilled:
9.Total well depth below land surface: S_
For multiple wells list all depths ifdifferent .;;713(� ( SUBMITTAL INSTRUCTIONS
WOft_) 24a. For—MIWells: Submit this form within 30 days of completion of well
,--. 9 construction to the following:
10.Static water level below top of casing: 6; (r
lfwater level is above casing,use 00 Division of Water Resources,Information Processing Unit,
I L Borehole diameter: 1617 Mail Service Center,Raleigh,NC 27699-1617
(in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method:_A Z, 0 i I i above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Cen'ter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test. 24c.For Water Suppiv&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount. completion of well construction to the county health department of the county
where constructed.
FormGW_1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016