GW1-2023-01176_Well Construction - GW1_20230127

WELL CONSTRUCTION RECO (GW-1
. ._) For Internal Use Only:
1.Well Contractor.Information:
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
Op ft' 320 ft
ft ft
NC Well Contractor Certification Numbery
IS.OUTER CASING for multi-eased wells OR LAYER rf a livable
r FROM TO DIAMETER THICKNESS I MATERIAL
Company Name ft ft iu
16.INNER CASING OR TUBING eothermal dosed-loo
2.Well Construction Permit#:_ ✓ T.O 0 `J Z. FROM 1�� DI 'MErER THICKNESS MATERIAL
List all applicable well construction permits(I e.UIC,Coon%Stale,Variance,e!a) .�. fG L j/� in r C Yam'
3.WelI Use(checkwell use): ft r7✓i in.
Water Supply Well: 7:SCREEN
. DAgricultural _ FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Mtlnicipa]/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single)
ft ft in.'
❑Industrial/Commercial ❑Residential'Water Supply(shared)
18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM I TO MA TrRL L EMPLACEMENTMEIHOD&AMOUNT
Non-Water Supply Well: D ft ft E�,I. � �
rOAquifer
g ❑Recove
ell: ry ft Y' ti a
echaz a ft ft
g ft.
orage and Recovery ❑Salmi Barrier 19.SAND/GRAVEL PAra livableFROM TO MATERIALMETHOD
qest ❑StormwaterDrainage ft fc
❑Experimental Technology OSubsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DES(!RIPTION volor,hardness soil/rock type.grain sae,etc
ft ft
4.Date Well �(s)Completed: —/9—23 Well ID# ft ft
Sa.Well Location: ft ft
��1 /l:[ pjt/ ft ft :.�" 9 ill .
Facility/Owne Name ft g
' Facility ID#(if applicable) � •uw
Ap /t
LLt\eLt ( 1\t► �[ tc I ('h0 D ,.ft ft 40 ,' 06
Physical Address,City,and Zip ft ft r�•i r ;` �^
�C'
21.REMAItI{S,f, �•1.'�ii.�i':
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification
l-20-23
6.Is(are)the well(s): ❑yermanent or ❑Temporary Signature bfCertified•Well Contractor Data
7�Q 3 By signing thisform,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ANo ISANCAC 02C:0100 or'TSA NCAC 02C.0200 Well Construction Standardr and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of thisfonn.
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 construction info
construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Rbniarks Box).'You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 L d (ft.)
For muh/ple wells list all depths tfdderenr(e.,Zple-3@200'and met 100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 7- 6 (ft) 24a• For All Wells: Original form to Division of Water Resources (DWR),
If water level is above'casing,use/"+' Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (�%d •(in•) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 0��,,, �,�y�
(i.e.auger,rotary,cable,direct push,etc.) I 24c.For Water Su, and Open-Loop Geotbermal Return Wells Copy to the
county environmental health depaz htrent of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d For Water Wells prodacinp over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permlt Program,1611 MSC,Raleigh,NC 27699-1611
• t5
13b.Disinfection type: Amount:
Form GW 1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6-20.18