_Well Construction - GW1_20230327 (47)

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
1.Well Contractor Information:
F�, �.-:'u'(-1��� ��1,�Ott+ `t�, �;�,�-�. la WATER zornas i I
WellConuactorName FROM To nFSCRIP1iox
n. tt.
NC Well ContradorCettiSrrtioaNamber 15 OUTERCASDYG(rormnlHmsedweIIs ORLIIVER da Lcnble
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1.J S +. vUr• �� \_. �L FROM TO I)LUXE ER TIIICHNE39 MATERIAL
M It in.
CompanyNamc
16 INNER CASING ORTUBING closed-lootil
2.Well Construction Permit#: FROM TO DMIErER IMCKHM MATERIAL
List all applicable well construction permits(i e.UIC,County State,YariancA etc) -/ ft. � fL
'1 m. {�!`
3.Well Use(check well use): D- ' ti- // 1D L� ti P�le
Water Supply Well: 17.SCREEN
FROM TO DIA11tLTM SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Mtmicipal/Public f- d`-J fc fa.
❑Geothermal(Heating(Cooling Supply) ❑Residential Water Supply(single) 1 �` `L! s
h IL m
❑Industrial/Commercial ,06sidential Rater Supply(shared) 18.GROUT
❑Irri ation s ❑Wells>100,000GPD FROM TO AUTER AL EiWLACEMFINTMETHOD&AMOUNT
Non-Water Supply Weil-
❑Monitoring ❑Recovery M M
Injection well: IL n
❑Aquifer Recharge ❑Groundwater Remediation
19.SANDIGRAVELPAQC da Ilcable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MAMMML I EWTI ACE UM MEMOD
❑Aquifer Test ❑Stormwater Drainage
GL�
❑Experimental Technology ❑Subsidence Control fL fL
❑Geothermal(Closed Loop) ❑Tracer 20.DRILIdNGLOG attachadditionalsheetsif
❑Geothermal(Heating(Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO DESCRWHON color.hudam su0/mdr e, sae eta
i fzli
4.Date Welt(s)Completed: Well ID# ; ft. Z'? R-
Sa.Well Location: n 3 fL
ft. D-
Facility/Owner Name JJ Facility IDff(if applicable) J/ ft
ft- IL
Physical Addrrs,City,and Tap
2L REMARKS A r•
LV
County Parcel Identification No.0?"
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
on(ifwell field, e latllong is sufficient)
' �ertd"ication �'
W N ��f` `'
6.Is(Are)the we11(s): ❑Permanent or ❑Temporary Signature of Cati&cd Wcll Contractor Date
Bysigning th-form,I hereby—!&that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 15A NCAC 02C.0100 or 15ANCAC 01C.0200 Well Construction Standards and that a copy
ffthis is a repair,f ll out known well construction information and explain the nature ofthe ofthis record has been provided to the wellaxmer
repair under Ul remarks section or on the back of thisfonn
23.Site diagram or additional well details•.
S.For Geoprobc/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 Ovee inRemarls Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (fL) corn
For multiple wells list all depths ifdii different(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the foltowi
10.Static water level below top of casing: (ft. 24a. For All Wells: Original�form to Division of Water Resources (MR),
Ifwater level it above casing,use"+ ) Information Processing Unit, MSC,Raleigh,NC 27699-1617
11.Borehole diameter: Ci 1 d (L) 24b,For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
.-) Program,1636 MSC,Raleigh,NC 27699-1636 ---.
12.Well construction method: { � l��'` 24c.For Water Supply and Open-Loop Geothenual Return Wells:Copy to the
(ie anger;rotary,cable,directpush;etc
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water.Wells Producing over 102,660 GPD_Copy to DWR,CCPCUA
' Parrott Pro 1611 MS et C 276 -1611
13a.Yield(gpm)61 fL'��-,='y Method of test: �''L'"'"�"'� ��' �'
13b.Disinfection type: LL*Y-';� Amount:
i
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Reso. Revised 6.6-2018
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