GW1-2023-00755_Well Construction - GW1_20230112

WELL CONSTRUCTION RECO .(GW-1
—) For Internal Use Only:
1.Well Co ctor.l of atio
" '14.WATER ZONES !
WellContractorName =TOTION
ft
NC Well Contractor Certification Number
1S.OUTER CASING for multi-cased wells OR LINER tfa lica-
w ��, FROM TO DIAMETER THICKNESS MATERIAL
Company Name as ft ft in. ,
�� / 7 _ 16.WNER CAS WG OR TUEING eothermal cloew loo
2.Well Construction Permit#: (o L. FROM TO DIAMETER THICIQYESS MATERIAL
List all applicable well construction permits AC-UIC,County,State,Variance,etc.) ft tt` in..
3.Well Use(check well use): M fL in.
Water Supply Well: 7:SCREEN
❑Agricultural FROM TO DIAMETER SLOT SIZE THICKNES S MATERIAL
❑Municipal/Public ft ft in
❑Geothermal(Heating/Coohng Supply) — sidential Water Supply(single)
❑IndustriaUCommercial ft ft in,
❑Residential'Water Supply(shared)
❑Irri ation 18.GROUT -
❑Wells>100,000 GPD FROM : TO MATERIAL. EMPLACEMENTMEIHOn&Ardowr•Non-Water Supply Well: ft tt
❑Monitoring ❑Recovery -
Injection Well: ft
❑AquiferRechatge ❑Groundwater Remediation it fc
❑Aquifer Storage and Recovery ❑Salinity Barrier . , 19'SAND/GRt1VELPACK rf a licabla
FROM TO MATERIAL EMPLACEMENTMETHOD
❑AgtriferTest ❑StorntwaterDr:Iinage ft ft
❑Experimental Technology ❑Subsidence Control' !t it
❑Ggothemlal(Closed Loop) ❑Tracer '20.DRILLING LOG attach-addiiional sheeb if aecessa
❑Geothermal(Heating/Cooling Return) ❑Other lain under.#21 Remarks) FROM TO DESCRIPTION color haraaess soiVracic io i ate
ft ft
4.Date Well(s)Completed:J-:3 2.3 Well m# ft ft
s Pam'
Sa.Well Location: ft ft 9022
Facility/Owner Name Fa ,ct7ity ID#(if applicable) ft ft:.
-TOYtk a.. Rd •
'� �c� S J-�• '•rt f< llr�vn s s.;>ca�.�r,,� gib:
Physical Address,City,and Zip ft '
�t3'l lien.PCB ` f t
�..y 21.REMARJLsJ
Covaty Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
3�
(ifwell field,one latlloag is sufficient)
" 22.Certification:"
Z-Lq_zz
6.Is(are)the well(s): D111"manent or ❑Temporary 1 Srgoahue o e�Nell Contractor Date
7.is this a repair toaneldsting well: Dyes. or BY signing thisfornr,lherebycert�that the well(s)war(were)constructedln accordance with
UPfo 1SANCAC 02C:0100 cr73ANCAC 02C.0200 Well Construction Standards and chat a copy
If this is a repair,fill out brown well construction information and explain the nature of the ofthis record has been provided ro the well owner.'repair under#21 remarla section or on the back of thisform
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 NUMBER of wells (add'See Over'in Rdmarks Box).You may also attach additional pages if necessary•
drilled:
9.Total well depth below land surface: �' Zo .� (ft) 24.SUBMITTAL INSTRUCTIONS. ,
For multiple wells list all depths ifdi/feretii(example-3@2001 a»d2p100� Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: S 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwarer level is above casin&;use (ft) Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: #n-) 24b.For Infection Wells:Copy to DWR,Underground injection Control(IUC)
a� Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:
(La.auger.rotary,cable,direct push,etc.) 24c.For Water Supply and ODen-Loop Geothermal Return Wells Copy to the
county environmental health department of the county where installed
FOR WATE,R SUPPLY ONLY:
24d For Water Wells Droducine over 100 000 GPD•Copytto DWR,CCPCUA 13a.Yield(gpm) Permit Program, MS
Method of test: �il,(JtJ C,Raleigh;NC 27699-1611 t ,
13b.Disinfection type: -+ f J Amount:
Form GW-1 North Carolina Department ofEavironmental Quality_Division of Waterltesourcea