GW1-2023-00736_Well Construction - GW1_20230113

print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.VY0 Contractor Information: I
.WATER ZONES
—FROM
R TO
DESCR�TION
Well ContractorrNNama �1• k. k•
ft. ft.
NC Well Contractor Certification Number 401nRCASING.fonior tl+cased iiveUs OR LINER ifs Iicable
TO DIAMETER THICKNESS MATE fL 1� in. . V
Company ame oo2.Weil Construction Permit#: GH�A-(Z� TO DIAMETERList all applicable well construction permits(i.e.WC,County,State,Variance,etc.) rL In•
k. tL in
3.Well Use(check well use):
17.SCREEN
Water SupplyWeU: FROM TO DUMETER SLOTSIZE THICKNESS MATERIAL
Agricultural [Mtmicipal/Pablic ft. k In,
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) k, fL
IndustriaUCorrunercial FRe,idential Water Supply(shared) 1s..GRQUT_
LTi HtiOn FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rr O L
Monitoring Recovery k. tL
Infection Well: ft. k.
Aquifer Recharge ®Groundwater Remediation 10.SAND/GRAVEL PACK.. f,a licable
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [StormwaterDrainage It k
;.�.
Experimental Technology [Subsidence Control tt, ft
Geothermal(Closed Loop) [Tracer 20.'DRILLING LOG.attach additional sheetsJf necessary)
P/tOM TO DESCRIPTION color,hardness sourrock size eta
RGeothermal(Heating/Cooling Return Other(explain under#21 Remarks 0 ft, 70 k•
4.Date Well(s)Completed: 2130 Well ID# 7 I fL d5 fL e'
% ft.
Sar.Well Location: k ft.
Lit F InOO eA/'
Facility/Owner Name Facility 1D#(if applicable)
tL
170ci 6wt�cm C� (�t�, ft. k. Aid i 2�23
Ph
ft. k.
sical Address,Ci
ty,ity,and Zip = t
k21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iattlong is sufficient) 22.Certification:
35,2y573 N 6.2_,00507 W
6
6.Is(are)the well(s)wermanent OrSignature of Certified Well Contractor' Date
[Temporary
BY signing/hJs form,/hereby terrify the!the well(f)sues(were)consmrcred to accordance
7.Is this a repair to an existing well: ®Yes or I40 with 15A NCAC 02C.0100 or/3A NCAC 02C.0200 Well Construction Standards and that a
If this Is a repair,fit/out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
•rdpair under#21 remarks section or on the back ofthis 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 site details or well
construction details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed.•Indicate TOTAL NUMBER of wells
drilled: - SUBMrITAi INSTRUCTIONS
9.Total well depth below land surface: Jr 5, (1`0 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(f oleerent(exoMple-3@200"and 2@1001 construction to the following:
10.Static water level below top of casing: 60 (B•) Division of Water Resources,Information Processing Unit,
If water lavel is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (�•) 24b.For Injection Wells: In addition to sending the form to the address in 24a
/ r� above,also submit one copy of this form within 30 days of completion of well
tJ
12.Well construction method: V u construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Infection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 4r'"_ 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit One copy of tins form within 30 days of
13b.Disinfection type: 1a rt vL6 Amount: G S completion of well construction to the county health department of the county
where constructed.
Revised 2-22-2016.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources