GW1-2023-00779_Well Construction - GW1_20230112

i
Point Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
1'4:'V(tAT R ZONES I i
FROM I TO DESCRIPTION
e11CContractor Name, ft. ft
`�✓L15%"r ft, ft. I
NC���VVVcfi Contractor Certification Number 15;OTl1R it CASING'.for ul 4lised wbM OIt.1.INER'if.a llceble
M s J ��� � � FROM TO DIAMETER THICKNESS MATERiAI,
l r l-t�� I ' n' q,5 f" 6.I2S in• ,50 2
Company N a /r 6,'INNERCASINGQR'T,IJHING edtBermal'cToaed•!ao
��S TCiVi FROM To DIAMETER TH[C[WESS MATEFUAL
2.Well Construction Permit#: 1,100,
ft. fa tn.List all applicable well construction permits a.e.(IIC,County,State,VaHonee,etc.)
3.Well Use(check well use):
-17.SCREEN
Water Supply Well: FROM TO DIAMETER I SLOTSIZE 1 THICIINESS MATERIAL
Agricultural [DMunicipaUPirblic ft. ft.
Geothermal(Heating/Cooling Supply) Water Supply(sinle),( h, ft. Iu
Industrial/Commercial [311 a,esideptial Wate6Supp S(shered) G:•1s.•i ItgUT
I[rl atlen C FROM TO MATERfAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: JAN L v Oft- a p ft
e yl. ) C
Monitoring ORecovery ;1 ftP fL
Infection Well: t___ „iC l?f^�:'3 "`J ft. ft.
1`p„,.,rr:,. 0G
Aquifer Recharge ®Grouddwater ReMi;BietionYt� 19,SAND GRAVEL PA IG.If•,a Itcalile.
Aquifer Storage and Recovery Ey)Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
l• ft. to
Aquifer Test [3Stormwater Drainage
4., �,
Experimental Technology ',t, y�,:• [3SubsidenceControl ft, ft.
Geothermal(Closed Loop) DTmccr 20.'DMLIN OG. ttach d itiboal:abeet. •if•neeessa ok sue eta
Geothermal(Heatin Cooling Retum ex Other lain under#21 Remarks FROM TO DESCRIPTIONcolor hardness s Wroc
g, a S tt.
4.Date Well(s)Completed: i' 3 _z Well ID# q6 ft. �yS ft. r4
ft. ft.
Sq.Well Location:
ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
r GS 5 1 7 A n, ft.
Physical Address,City,and Zip
ZT.REMARKS
County Parcel idendficationNo,(PIN) •-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:'
(if well field,one lat/long is sufficient) 22.Certification:
3.5 ,3 -3 5— w
Signature ofCertified'Wa1lContractor Date
6.Is(are)the well(s)iMPermanent or Temporary.
By signing this form,1 hereby certo that the wells)was(were)constructed in accordance
7.Is this a repair.to.on existing well ®Yes or,oNo with iSA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ijrhis is a repair,Jill our brown well construction information and explain the nature jthe copy ojthts record has been-provided to the tivell owner.
rdpa/r under#21 remarks section or on the back ojthis form. 23.Site diagram or additional well details:
8,For Geoprobe/DPT or Closed-Lbo' eothDrmal Wells having the same You may use the back of this page to provide additional well site details or well
p construction details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed.'Indicate TOTAL NUMBER of wells,
drilled: 4TTBMITTAL INSTRUCTIONG
9,Total well depth below land surfdce: `>f 5 (ft) 24a. For Ail Wells: Submit this form within 30 days of completion of well
par multiply wells list ail depths lid fferent(example-3 200"and 2@1001 construction to the following:1
10.Static water level below top of casing 60 (ft.) Division of Water Resources,Information Processing Unit,
/jwater level is above carldg,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
in. 24b.For Infection Wells: Ti addition to sending the fortis to the address in ea
11.Borehole diameter: ( )
• above,also submit one copy lof this form within 30 days of completion of well
12.Well construction method; A '' construction to the following:
(i.e,auger,rotary,cable,direct push etc.) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
m
13a.Yield(gP ) Method of test: X 1 r 24c.For Water SunDly Bc Infection Wells: In addition to sending the form to
I_ the address(es) above, also 'submit one copy of this form within 30 days of
�t C. Amount: � S completion of well construction to the county health department of the county
13b,Disinfection type:C%Vl� Yl Ci�
where constructed, f
North Carolina Department ofEnvironmanW Quality-Division of Water Resources
Foot OW-1
Revised 2-22-2016
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