_Well Construction - GW1_20230315 (54)

WELL CONSTRUCTION RECO _ GW-1 For Internal Use Only: .
1.Well Con etor.Info tion:
i
'14.WATER ZONES
Well ContcaetorName FROM TO DESCPJMON
.3535 too ft, ouft
NC Well Contractor CertificationNumber
n I5.OUTER CASING for multi-cased wells OR LINER rf a Gn61e
FROM TO DIAMETER •rHIQft
OVESgrg ,
Company Name �•
16.INNER CASING OR TUBING eothermal close
2.Well Construction Permit ft (_J (l!�e FROM To DIAMETER THICI4YESg
GO MATER
List all applicable well construction permits(Le.WC Comfy,Slate,Variance,eta) { ' ft
3.Well Use(checkwcll use): & T R
Water Supply Well: J7.SCREEN
❑A cultural FROM TO DIAMETER SLOT SIZE TM(!T0 Vz MATERIAL
gn ❑Mtmicipal/Public - ia.
❑Geothermal(Heating/Cooling Supply) te'l-slidential'Water
idential Water Supply(single) ft �.
❑adust ial/Commercial Supply(shared)
18.GROUT
❑Lei tiolt ❑Wells>100,000 GPD FROM To TERLw LUIPLACUaNT" EIBOD&AMovxr
Non-Water Supply Well: n^�
❑Monitoring ❑Recovery ft fa e (ill ,, t'
Injection Well:
❑A Aquifer ft ft
q �e ❑GroundwaterRemediation
❑Aquifer Storage and Recovery ❑SalinityBanier 19'SAND/GRAVEL PACK ifa licable
FROM TO MATERIAL EIVIPIACEMENTbM1 OD
❑Aquifer Test ❑StormwaterDrainage ft: ft
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop). ❑Tracer 20.DRILLING LOG attach additional sheets if neeessa
❑Geothermal(Heating/Cooling Return) 170ther( lain under#21 Remarks) F1toM To DESCRIPTrON color,hardness soiVroek q is sae etc
ft:
4.Date Wells)Completed: Z Well ID# ft ft.
Sa.Well Location: ft ft
Facility/Owner Name Facility IDff(ifapplieable) fL ft
4Sevi n � 1Zo► .. ft
Pbysical Address,City,and Zipft.
ft
21.REMARKS,( .V ;
County Pmtd IdeutificationNo.(PIN) _;C
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: tie'" `'`.•...°'' '
(ifwell field,one IatIlong is sufficient)
3 II 22.Certifrc tion:
bt 7 t I N I `�' � W 6 g.
6 Is(are)the well(s): ❑Permanent or ❑Temporary a r Sigoahn:o Certifi •Well Contactor
Date
7.Is this a repair to an eAsting well: ❑Yes or l rlo yAN�C.4C 01C:0100 or� t 02C 020o(�was
cvnw.rr�rue on S min, m�ra o .
Ifthis is a repair,fill out known well com action irformadon an lain the nature ofrhe. of this record has been provided to the well owner.
repair under 01!remark section or on the baekofthhform.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells havingthe same You may use the back of this page to provide additional well construction info
construction,only 1 GW 1 is needed. Indicate TOTAL NIJ MER of wells (add IS-Over'in Remarks Box).You may also attach additional pages ifneeessaiy.
drilled:
24.SUBMI TAL INSTRUCTIONS
9.Tofal well depth below land surface: t7 f (ft)
Formultiple wells list all depths jdperenr(example-3(a)100'and1Ql00� Submit this GW 1 within 30 days of well eompletion per the following.
10.Static water level below top of casing. ( ) 24a. For All Wells: original form to Division of Water Resources
Ifwater level is above earin 'use"+" �� (DWR),
�. �a Infoimation Processing Unit I617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter. 3 (m.) 24b.For Injection Wells:Copy to DWR,Underground Inlechoa Control(iUC)
n Program,1636 MSC,Raleigh,NC 27699-1636 12.Well-construction method:
(Le.auge,rotary,cable,directpusb.etc.) 24c.For Water Su I and Onen-Loon Geothermal Return Wells-
FOR Copy to tree
county environmental health department of the county where installed FOR WATER SUPPLY WELLS ONLY:
24d,For Water Wells Drodnciae over 100 000 GPD Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Penner Program,1611 MSC,Raleigh,NC 27699-1611
113b.Disinfection'type: N - A mounti (�z
Fran GW--1 Northcuolini
epaclmentcamVironmental Quality-Divisionofw•at'u.•,:..----