GW1-2023-00877_Well Construction - GW1_20230118

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well C or Information: ^ + p
r r14: ER ZONES
FROM TO DESCRIPTION
Well Contractor Name. fr. ft.
n ft.
NC Well Coopgctor Certification
Number I AN 1 g 2Q23 16.MITER•CASIT!IG.for iau. cased wells OR t2TI tea Acable
r � J� FROM fr. TO DIAMETER In. 5D oC-) MATERIAL
Company Name lf�Ir`W�Qt: 16.'INMER CASING ORTUBING edthermgl efesed-loo
n ��. FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: /' , tt. ft. �
List all applicable well construction permits fl.e. C,County,State,Variance,etc.)
fr, ft. in.
3.Well Use(check well use):
i7.SCREEN
FIndustriallCommercial
ply Well: FROM TO DIAMETER SLOT SUM THICKNESS MATERIAL
ral E)Municipal/Public fr• ft. In.
mal(Heating/Cooling Supply) ro<odential Water Supply(single) ft, fL In.
Residential Water Supply(shared) 18.-QAtOUT
FROM To. MATERIAL EMPLACEMENT METHOD&AMOUNT
Irri ation ft, a2Q £L
Non-Water Supply Well:
Monitoring Recovery fr. fr.
Injection Well: �Cdt Remediation ft. ft.
Aquifer Recharge Groundwater 19.SAND/GRAVEL PACK.►f.a licable
Aquifer Storage and Recovery .Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
.
DStormwater Drainage
ft. ft
Aquifer Test `t„ g
ft.
Experimental Technology [38ubsidence Control ft.
Geothermal(Closed Loop) Tracer 20.'DRILLINGLOG.attach ddItibnala eetsa6necessa
FROM TO DESCRIPTION color hardness 90 rack size,etc
RGeothirmal(Heating/Cooling Return) n.Other(explain under#21 Remarks) 10 ft. fr, }, a
4.Date Well(s)Completed: 4 3 Wep ID# r 67
ft. ft.
Sa.Well Location:
t
Facility/Owner Nema Facility ID#(ifap ficable) ft.
priYce' ft. fL
Physical dres, ity,end Z
21.REMARKS
P Lc ri
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/second or decimal degrees:
(if well field,one IaUlong is sufficient) 22.Certification:
35, 45-46* N
t. Date
Signature of Certified Well Contractor
6.Is(are)the well(s)iPermanent or Temporary
By signing this form,I hereby certify that the wells)ivas(were)constructed In accordance
7.Is this a repair to an existing well: ®Yes or E[No with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill 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 of this form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-I oojrGeoth¢rmal 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: 2 SUMM—Iff-AL IN
9.Total well depth below land surface: if. 1 a� (W 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths Ifdfflerent(exRMple-3 a200"and 2@100) construction to the following:
10.Static water level below top of easing. /a (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use
/+"l 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: W (�•) 24b.For Inlection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: {�D 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: t 1, 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield.(gpm) LL Method of test: Gt—� / 24c.For Water Supply&Inlection 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: t= r Amount: �/ S completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources
Revised 2-22-2016 '