GW1-2023-01044_Well Construction - GW1_20230125

WELL CONSTRUCTION RECORD(GW-1). For Internal Use Only:
1.Well Contrac Ipf rmetion: 4 I f
/ t
0 14 WATERZONES I
WeilCormasxName FROM TO DESSC[tIPTION
fL
{O Cp ft
y� ft. J fL
NC WeU Cofactor C ' on Number :1&.OUTER,CASINC: for multi-eased .` OR LINER d
/ FROM . TO DTAMEIER THICKNESS MATERIAL
ftSF� & in. if C.
Company Name /1 16:1N1t1 GASING•O121TJBINEx:
2.Well Construction Permit#: �7 o S6 FROM DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permtts(t.e.UIC,Como,,Stare,Variance,eta) It. i
3.Well Use(check well use): /fLV/1
fL
to
I
Supply Well: '1T:SCREEN`
FROM TO DIAMETER SLOTSTZ£ THICKNESS MATERIAL
ultural 1 ctpal/Public 0.. ft ;a
hermal(Heating/Cooling Supply) Residential Water Supply(single) fG m
triaI/Commercial 13Residential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLA ENT'METHOD do AM
ater supply Well R c) fr O
itoring Recovery ft. ft
on Well:
ft.- %
fer Recharge rJGroundwater Remediation 19..SANDIGRAt. f`PAEB k
fer Storage and Recovery Salinity Barrier FROM MATERIAL EMPLACEMENT METHOD
fer Test' ElStormwater Drainage & fL
Experimental Technology Subsidence Control &
hermal(Closed Loop) Tracer 38rDRIT.i31!tG'.fAt;..atmrLsdt)it;timtlsLeett;'
hermal eatin Cool' R ) _. Other(explain under 921 Remarks) FROM TO I DFSCRLPTTON color,hard,m1frock pla,-grmn sme,etc
.. ft &
4.Date Well(s)Completed: Well ID# 7 S fL b &
5a.Well Location: & fL
_ i
S & k
Fatuity/O was�N=c / ! Facility ID#(if applicable) fL �i fi It _q
�GC Ad ft &
Physical r
City[.aid Tap & fL
1 l0it Zs.1tEAL4RKs __ ,i,
Comity Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one IzOong is sufficient) 22.Certification:
N W
� 2
6.Is(are)the well(s)W, Pe=rmmnent or re Tempo�N.
Signatu of Certified Well Cc Date
By signing this form,I hereby certify'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or with ISA NCAC 02C.0100 or l5A NCAC 02C.0200 Well Construction Srmtdards and that a
!f rhts is.a repo r fill r;!lataem well eonstrtction tnfornation and cxphrin the nanrre of the copy ofrhis ruord f as bee.:prorid-ed ro the well owner.
repair raider R21 remarks-section or on the back of thtsform.
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,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ) t (f) 24a. For All Wells: Submit this,form within 30 days of completion of well
For multiple wells list all depths if different(hmnple-3Q200'and 2@1001 construction to the following:
10.Static wafer level below top of casing: S� (fL) Division of Water Resources,Information Processing Unit,
if water level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well constriction method:
above,also submit one copy ofi;this form within 30 days of completion of well
—�� �a f
(i.e.auger,rotary,cable,direct push,eat.) construction to the following: i ,
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY LLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
I
132.Yield(gpm) Method of test: 24c.For Water Sunpiv&Injection 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 f/ Amount: O Z completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Depmtncnt of Environmental Quality-Division of Water Resource Revised 2-22-2016