GW1-2023-01502_Well Construction - GW1_20230209

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only.
1.Well Contractor Information:
14.WATMR ZONES I
FROM TO DFSCRD'TION
well Conuact"Name P/
IL
NC-ell ContrcoriDeLtificgatitionNumber g 15.OUTER CS formuDltIlA-MasEefd@wt els OR � da 1e
1
FROM OG
J
MATERIAL
ft fG i in.
CompanyName
y Y 16.INNER CASING OR TUBING eothermal closeddoo
2.Well Construction Permit#: T I � FROM I To DLOAL"ER I THICCRNFSS MATERIAL
List all applicable well construction perm^ ils iLelEffC.Cmmty.SY414 Variance.etr-) .4/ 'L R- �I tn' 'r (fL VO ,,
3.Well Use(check well use): R' lb3 IL it, tD 6cl--
WaterSupply Well: 17.SCREEN
FROM TO mium ER SLOTSrldi THICKNESS MATESW.
❑Agricultural - ❑Municipal/Mlic n sla A R 11 in.
❑Geothermal(HeatinglCooling Supply) ❑Residen�ttial Water Supply(single) ft., IL In
Dlndustnal/Commercial @resi��dential Water Supply(shared) 18.GROUT
0hriaation j ❑Wells>100,000 GPD, FROM TO AM E[VH'LACKMEMAETHOD&AMOUNT
Non-Water Supply Well: IL M 1 /�
❑Monitoring ❑Recovery & IG
Injection Well:
n n
❑Aquifer Recharge ❑Groundwater Remediation-
19.SANDfGRAVEI.PACK rifapplicable)
❑Aquifer Storage and Recovery ❑Salinity Bar ier FROM To I M&TERLAL I E M ACEMEM METHOD
❑Aquifer Test ❑StormwaterDrainage R 3 n: e-t-e—
❑Experimental Technology ❑Subsidence Control IL R
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if
FROM TO DESCRE TION color,hardnem sail mek s@,etc
❑Geotherntal(Heating(CoolingRetum) ❑Other(explain under#21Remarks) lA �. v � s�'
CJ
4.Date Wells)Completed: t' `z3Wellw# —.2-< 'L 'L 3Z2 bJ
Sa.Well Location: �v 'L rz
M IL
FacilityfownerName Facility ID#(Napplicable) ft. It
Physical Address,City,and Zip C C D L n l 2
56)0-`r�— Lai�� 04421
`i,1- 2L REMARuc
U
County Parcel( Identificatiion?No.(PII� rC•Gr: 'i^ :arnr ��
5b.Latitude and longitude in degreesfminutes/seconds or decimal degrees:
(if weH field,one Wong is sufficient) ` 1l 22.7efion,
5-6 1,7: 3 Zt1 N T7 3 3 r✓ W
6.Is(are)the we0(s):AaPermanent or ❑Temporary Signature of Certified well Contractor Date
BysignimSthisfonn.I herebycertifythat theweft(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNtr--- 15A New 02C.oio0 or ISANCAC 02C.0200 Well Construction Skmku s and that a copy
If this is a repair,fill out brown well construction vrformation and esplahr the nature ofthe ofthiT necordhas been provided to the well owner
repair under 021 remarks section or on the back ofthisform
23.Site diagram or additional well details:
S.For GeoprobeMPT 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 OW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Bo)C.You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ( ) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths rfdii Brent(k maple-3Qa 200'and2Qa 100)
i
10.Static water level below fop of casing: ( ) Na.For All Wells. Original form to Division of Water Resources (DWR),
10.St r level water
0ab ve casing:use o � Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwq it 24b.For Infection Wells:Copy,to DWR,Underground Injection Control(IUG)
11.Borehole diameter. fin-) Program,1636 MSC,.Raleigh,_NC 27699-1636
iZ Well construction method: Al t-0 2C ie� lac,For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(r a auger,rotary,cable,direct push,ctc.) county environmental health depsutrac t ofthe county where installed
FOR WATER SUPPLY WELLS ONLY: .24d-For Water Wells vrodclng over 100,000 GPD:Copy to DWR,CCPCUA
Permit Progmm,1611 MSC,Raleigh,NC 27 99-i 1
13a.Yield(gpm) Method of test: ,Q&d.322
13b.Disinfection type:b Je-11.l�f/'t`_ Amount: /LA G l(
Form GW-1 North Carolina Department of Environmental Quality-Division ofwater Resoraces, Revised 6-6-2018