GW1-2023-01496_Well Construction - GW1_20230209

WELL CONSTRUCTION RECORD (QW-1) For Internal Use Only:
1.Well Contractor Information:
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Well Contractor Name FROM TO I DES N
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NG well LourracLor"Tulwdiwn Nuluocr
fs-�OUTFR *tnij�w LIAM—Af Ai
r_1 y-t'J U Im FROM TO DIAMETER THICKNESS MATERIAL
Company Name n
1.6.IR�NVNEIER ING OXT •
2.Well Construction Permit#: EVI 0 00 FROM TO DLAmETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State, Variance,etc.) ft• ft. in.
3.Well Use(check well use): ft. ft.
Water Supply Well: F17;.SCREtN. ".7731- H ME1
I FROM I TO .1 DIAMZTKR .1 fflOT91Z9 .1 7MCkWM .1 MATIERTAt"
Lilhunicipall?ub'hu it. ft. lia. I I I
ClGeothermal(Heating(Coofing Supply) Wkesidenti.1 Water Supply(Single)
131ndustrial/Cornmercial CResidential Water Supply(shared)
ElIrrigation OWells>100,000 GPD FROM TO MATE kL I EMPLACEMENTMETHO OUNT
Non-Water Supply Well: 0 0 0 1/av'b�
OMonitoring CRecovery ft. ft.
Injection Well:
0Aquifer Recharge OGroundwater Remediation
DAquirer.storage ana Recovery L-ILMIMiLy names FROM I TO i MATERIAL I EMPLACEMENT METHOD
OAquifer Test OStormwater Drainage fL ft.
OExperimental Technology OSubsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer _46.DRIFLSG LO G_ 4attach ad
CGeothermal(Heating/Cooling Return) 00thet(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,solYrock tym uxin dzp,e6c.)
ft. a ft.
4.Date Well(s)Completed: 0 0-11- Well ID# 0 0 It.
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Facig415
' /06erName Facility rD#(if applicable) ft. F�Q i
of,�V)A VV\ r a Ze, ObY) ft. ft. 3
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Physical Address,City,and Zip ft. ft
6 017013 - 21 n4kPJM;W; o!", AA
County Parcel Identification No.(PIN)
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(if well field,one lat/long is sufficient) 22.Csymcation:
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6.Is(are)the wel1(s): 41PIrmanent or OTemporary SiZA of Certified Well( I tractor Date
B signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
17�i��111
7.Is this a repair to an existing well: 11Yes or OR/No TSA NCAC 02C.0100 or JJA NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the m,11 owner.
repair under#21 remarks section or on the back of this form. 11-2 044.Ad--— AAW"­1­311 A­!15..
S.For Geoprobe/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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: i / v 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: —(ft.) Submit this GW-I within 30 days of well completion per the following:
For multiple wells list all depths ifdiffereni(example-3@200'and 2@100�
-2, 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use­+"
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where—InstaMe—d
FOR WATER SUPPLY I WELLS ONLY: 24d,For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount: