GW1-2023-01494_Well Construction - GW1_20230209

WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only
1.Well Contractor Information:
lot .6 0 V\ C6G L� :y1tA I E 'L017ESr� t,r'..d u,> ??��' "s,3"a c ; l$t'!FTP ,',i;u,:`a
Well ContractorNatne FROM TO DESCRIPTION
ft. ft. 10 6 Yt
J1 ft, ft.
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�� A` fl ,,p C i t n FROM TO DL1d9ETER THICI4NT�SS AdATMAL
(�l YJ W tK ft. / 6 ft, !n. 1545
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Company Name _
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2.Well Construction Permit#: Z FROM I TO DUtrtETER I THICENESS MATBRL41
List all applicable well construction permits(t.e. U1C,Couno,,State, ariance,etc.) ft. 0 L'ft, �' In.
py
3.Well Use(check well use): in,
Water Supply Well: ',k7" LkV;-`` •,' ;,. �,�'x,Aa�A..,� ;��};;' .:, .. �,�, : ;.�:=.` da~�,
FROM TO DUMETEA SLOT SIZE THICKNESS MATERIAL
_,ter "ii^L uivsuuicipdviUu!!u �. >..
❑Geothermal(Heating/Cooling Supply) 4esidential Water Supply(single) g R, in,
❑Industrial/Commercial ❑Residential Water Supply(shared) $ ..a ;<
❑Teri ation ❑Wells> 100,000 GPD I FROM TO MATERIAL y. EMN ACEIN-0NT METHOD&AMOUNT
Non-Water Supply Well: it, 2-0, R. ell ; y"Ey
❑Monitoring ❑Recovery ft. ft.
Infection Well: R. it.
OAquifer Recharge OGroundwater Remediation ;_ irtt
OAquiffefStorage and Rr=rttw 1Na!-,n1".t na-icr i LArw ! T' iiiJTSRiAr. i F:inr.,.f'Eiv7&-�..is$i dGD
❑Aquifer Test ❑Stormwater Drainage R
❑Experimental Technology ❑Subsidence Control ft. 1t•
❑Geothermal(Closed Loop) ❑Tracer ISItIfe .ddditTu s7taetlfttecesi hi '6 �r <'
❑Geothermal(Heating/Cooling Return) ❑Other e lain under#21 Remarks) FROM TO DESCR?TION(color,hardna soil/rock ain she,eta)
ft 0,0 ft. el a.
4.Date Well Completed: L-3-L-2-5 Well M# 163 It. (J n• 0 c K
u O�b
1el ;
Facility/Own Name Facility ID#(if applicable) IL R. -
�-`J 4 A ' }� W 4 rli ic. ft.
Physical Address,City,and Zip 1t ft.
County Parcel Identification No.MTN — h le -n C i 5-rod`
i� A A A _111.1 M
L' t _
Sb-t,ntstVto nnrt-tnne meta.in ryP,r a:;narrarsecoaas or aecamai aeareci: —--_
(if well field,one lat/long is sufficient) JCNW6.Is{are)the well(s): ermanent or ❑Temporary Certified well Co ctor Date
signing thisform,!hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o MA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards 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 this form.
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8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same A- •,.,., �� w�� �•�i -a- �r� �- ���� - -� -______ _
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: I ^ A 6 24.SUBMITTAL INSTRUCTIONS
9,Total well depth below land surface: '�A` —(ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths tf d fferent(example-3Q200'and 2@1000
10.Static water level below top of casing: CJ (ft.) 24a, For All Wells: Original firm to Division of Water Resources (DWR),
If water level is above casing,use"+"
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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program,i ti3ti iviSC,,Fcsieigit,ii,r 27o�i-i o30
12.Well construction»method: C( i I 24c.For Water Su 1 and Open-Loop Geothermal Return Wells:Copy to file
(i,e.auger,rotary,cable,direct push etc,) county envlronmental health department of the county where Installed
FOR WATER SUPPLY WELLS ONLY: ! 24d.For Water Wells rodudng over 100,000 GPD: Copy to DWR,CCPCUA
13a,Yield(gpm) �� /- Method of test: w Permlt rogt'sm,1611 MSC,Raleigh,NG 27699-1611
11h.THAnforHnn lvnn: t Amount: �l -