_Well Construction - GW1_20230320

WELL CONSTRUCTION'R]ECO ( ) For Internal Use Only:
1.Well Contractor-Information:
*Ah14.WATER ZONES
Well Coa r.ame FROM TO I DESCrtLPTTrON
• 3�'3 5 l00�' aov�
ft ft
NC Well Contactor CettificationNumber
�yJ R 1.
15.0 CASING for multi-cased wells OR LINER rfa Gable
_/ "Gt4jl FROM 1 TO DIAMETER TMCKNESS MATERIAL.
Company Name
ft ft is
16.INNER CASING OR TUBING eothermal elo!fed-looni
2.Well Construction Permit#: C/O O l.(l FROM TO_ DrA1�tErElt rSIC[nvcss ntArExrAl
List all applicable well e0nmuetion permits.(i e.WC County,State Yarianm etc) �. 1 ftft JC�� m fIL K1
3.Well Use(check well use): ft ft in.
Water Supply Well: J7.SCREEN
❑A cultural FROM TO DIAMETER SLOT SIZE TSICIQYF.SS MATERIAL
gn ❑Municipal/Public tt ft is
❑Geothermal(Heating/Cooling Supply) - Cidential Water Supply(single) it ft in'
❑Industrial/Commercial ❑Resldential'Water Supply;(shared)
18.GROUT
Chrigation ❑Wells>100 000 GPD FROM TO MATExrAL EMPLACEMENTMErHOD&AMOUNT•
Non-Water Supply Well: 0 ft 2 3 ft e�4 fi
❑Monitoring ❑Recov Y
Injection Well: f t Od`7'/ tom+ s t
❑A uiferRech a ft ft
4 • � ❑GroundwdterRemediation
❑Aquifer Storage and Recovery ❑Salty Barrier FR0 /GRAo LPACIC Mapplicable)
1�iiccablble
EMPLACEMENT METHOD
❑Aquifer Test ❑StonnwaterDrainage ft ft
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets ifnecessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DEst3uPrloN error,Lvdaess serVroek ;n srse eea
fG ft
4.Date Well(s)Completed: .3.1 5- 2-3 Well ID# ft ft
5a.Well Location: it ft
was 61-1 00 ill t a,r y ft
Facility/Owner Name pp '� Facility 1D#(if applicable) ft ftMAN
�.�. C�t.C..F� -(J1}oLp.,lL� l�d� (�� •-•ft ft
Physrcal Address,City,and Zip t,fi'.i
21.REMARKS,(
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/urinates/seconds or decimal degrees:
(ifwwcH field,one lat/iong is sufficient) 22.Certification:
.6.Is(are)the well(s): 9kermanent or ❑Temporary 5�8 o estefidd Well Contractor Date
Bysign/ng thirform,Thereby eernfy that the weQ(s)was(were)comvi cfed in accorda:se wish
7.Is this a repair to an existing well: ❑Yes or dJNo 1SANCAC 02C:0100 or*25ANCAC 02C.0200 WeQ Construction Standards and that i copy.
Ijthis is a repair,fill m 1wowa weft construction injormation an esplaln the naft e:0j/he. ojth/s record has been provided to the weQ owner
repair under#21 remarks section or on the back ofthisjoins
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 constructim info
construction,only 1 GW 1 is needed..Indicate TOTAL NUMBER of wells (add'See Over'in R6marks Box).You may also attach additional pages if necessary.
drilled-
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:For mult6ple wells fist all depths ijdgerent(=ozmple-3@200 and 2©100) (ft) -Submit this GW-1 within 30 days of well completion per the followLg:
10.Static water level below top of casing._ (� d ft 24a.•For All Wells: Original form)to Division of Water.Resources (DWR),Ijwater level is above eosin&;use"+^ ( ) Infonnati0n Processing Unk 1617 AI§C,Raleigh,NC 27699-1617
11.Borehole diameter. rj I Cm� 24b.For Infection Wells:Copy to DWI;Underground Injection Control(IUC)
n Program,1636 MSC,Raleigh,NC 27699-1636
12 Well construction method: Re Ea h., _/7yY'.
Cie.augeg rotary,cable,directpusb:,etc.) ' 24c.For Water Supply and Ooen-Loo Return Wells.Geothermal Retu Wells..C.opyIto the
county environmental health deparhment of the county where instailni
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells prodacine to er 100 000 GPD•Copy to PennTt DWF,CCPCUA
Pro 13a.Yield(gpm) � � Method of test: Z Z 6' gram,1611 MSC,Ralelgh,'NC 27699=1611 S '
13b.Disinfection type: Amount;
Form GW-1 North Caro
lima Department ofEavimmaental Quality-Division of WateiResomccs
Revised 6-6-2018