GW1-2023-00993_Well Construction - GW1_20230118

Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Inf rma on:
L Y�� E'- - = 1'4.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name,
m
tr /� fr. ft I
'L 1 4,rA ft. N
NC Wall a tractor Cartificatto Numbar nn �• 15,OT1F11bCAS .G',foriau) •cased wolfs OR INER'ilia cable MATERIAL
_ �/S I ( � ��).yLa FROM �• To a D ,Z, Im,TER I THICKNESS
s`1s
Company Name ) 16.'INMR.CASINGORTtJAI1VG> 'edthermgl'olosed-too
2.Well Construction Permit#: LLY` e� f�' 7fL
To DranmTER TmctwEss MATEmAL
List all applicable well construction permits(t.e.UIC,CountyStale,Variance,etc.) ft. fL ft. In.
3.Well Use(check well use):
1Q.SO EN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICIOVESs MATERIAL
Agricultural E cipal/Public fL fL in.
_ Geothermal(Heating/Cooling Supply) tsidential Water Supply(single) ft, ft. In.
[3Residential Water Supply shdare
3ndustrial/Commercial pp y( ) 1s..tzR•I1T
Irri at10n FROM TO MATERIAL EMPLACE T METHOD&AMOUNT
Non-Water Supply Well: -o I BOyl-ICri 6 � b0 5
Monitoring MReoovery ft ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation 19. ELOG.(aZ.tta_e
It;a Itca6=EWLACEMENTAquifer Storage and Recovery' .: Salinity Barrier FROM KATERIALAquifer Test � u �,� , [3Stormwater Drainagett.Experimental Technology Subsidence ControlGeothermal(Closed Loop) Tracer 20.'DRILLI dditlomal
FROM ro DESCRIPTION color hardneu 80WAV size etc
Geothermal(Heating/Cooling Return) n.Other(explain under#21 Remarks b M fr, +���� f
4.Date Well(s)Completed: �Z WeB Y-a- i 2
fL ft. Lj
Sit.W Location: ft. ft.
l GLY1 f r tr—
'I� E Pi
Facility/0 ner Name Facility IDN(if applicable)
ft. ft.
s m ft. JA N 2023
ft. ft.
Physical Address,City,and Zip ., .,� pjryj
2I. MARKS
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wen field one lat/long is sufficient) 22.Certification:
v Signature ofCertified Well Contractor ._ Date
6.Is(are)the well(s) rmanent or Temporary
By signing this form,/hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or RNo with MA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
ljthis Is a repair,fill out known well construction information and explain the nature ojthe copy of(his record has been provided to the ivell owner.
rdpair under 021 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.For Geoprobe/DPT or Close,&Dttop'l eothcrmal Wells having the same construction details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed,'Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land si&feee / A) 24a. For All Wells: Submit this form within 30 days of completion of well
par multiple wells list all depths IfdiTerent(g:rample-3@200"and 2Qa 100� construction to the following:
10.Static water level below top of casing:" I .Z._O (ft.) Division of Water Resources,Information Processing Unit,
"+"I/ 1617 Mail Service Center,Raleigh,NC 27699-1617
Ijrvarer level Is above casfrig use
11.Borehole dia meter: / (�•) 24b.For Infection 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: }�� _ construction to the following:
(t.a,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
In addition to sending the form to
13a.Yleld.(gpm) Method of test: 4.1 .r 24c.For Water Sunn ly&Intlection Wells:
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: L D f�l rl C Amount: G s completion of well construction to the county health department of the county
where constructed.
sIoo of Water Resources Revised 2-22-2016
Form OW-1 North Carolina Department ofEuvtronmoutal Quality-
Divi