GW1-2023-01495_Well Construction - GW1_20230209

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14
Well Contractor Name ,
v fJ P06)'e—
FROM TO DESCRIPTION
ft.
2.o qrM
A
NC Well Contractor Certificatifn Number
ra� rN I FROM TO DIAMETER -THICKNESS MATERIAL
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Company Name
2.Well Construction Permit#: z 2e6 FROM TO MATERIAL
List all applicable well construction permits C1.e.VIC,Couno,,Slate, Variance,etc.) R. ft. in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: 1,7,,,,5CRF__F M To DIAIMETER SLOT SIZE THICKNESS MATERIAL
ClAeTicultural FlMunicinal/Puhlir
DGeothermal Cricating/Cooling Supply) residential Water Supply f Single)
ClIndustrial,lCommercial CResidential Water Supply(shared) 18.GROUT
C31rrigation OWells>100,000 GPD FROM TO MATEXAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. —L 0 ft-
ElMonitoring CRecovery ft.
Injection Well:
ClAquifer Recharge OGroundwater Remediation
a app
ClAouifer qtorao"and r-
Rernvry 19.SAKDiGR�kVELIACK t IiNiblc
OAquifer Test LJStormwatcr Drainage fL
OExperimental Technology OSubsidence Control ft. ft.
ElGeothermal(Closed Loop) CTracer 11L.DRILLING LOO�artach addition
2"M
DGeothermal(Heating/Cooling Return) []Other(explain under#21 Remarks) J FROM TO DESCRUT[ON(color,hardnes.%soll/rock type,grain size,etc.) 1
6 IV R. I -hop.5 0 '1
0 I I
4.Date Well(s)Completed: Well ED# R. 1 6 ft. re I ON
Sa.Well Location: ra
_5 b i r_s
Facility/Owner Name Facility ID#(if applicable) ft ft,
` 51 � fL
Physical Addr City,and Zip ft. ft.
ft Ls_-]�d z .-- -!ft'.t
County Parcel Identification No.(PIN)
5b.Latitude and loneitude In dePreerJrnInutP.qlqPrnnd%nr dpelm I d­
ffwell neid,one latliong is sutticient)
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6.Is(are)the well(s): 4plermanent or OTemporary CeKAd We 4,0 traC'r0—rL--/1— Date
signing this form,I wfify that the well(s)was(were)constructed in accordance with
SiY
7.Is this a repair to an existing well: []Yes or M(Nlo 15A NCAC 02C.0100 7541ANICACO2C,02(10 Well Construction Standards and that a copy
{flhis is a repair,fill out known well construction information and explain the nature ofthe ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:—I— 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 0 —(ft.)
For multiple wells list all depths i(different(example-3@200'and 2@100') Submit this GW-I within 30 days of well completion per the following;
10.Static water level below top of casing: 2A (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: 24b.For Injection Wells: Copy to DWR,Underground Injection Control(TUC)
24c.For Water Slupgly and Open-Loop Geothermal Return
12.Well construction method: Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc,)
county environmental health department of the county where 't.
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: ID W Permit Program,1611 MSC,Raleigh,NC 2769-9-16-11
13b.Disinfection type: Amount: -2-