GW1-2023-01503_Well Construction - GW1_20230209

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only.
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1.Well Contractor Informa,,,tiioow. {1 f
Inn"a�-tr Y'�.✓4,A� I 14.WATER ZONES
WellConuactorName FROM To DFSCRwnoN
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NC�/Weell Contractor CudfieationNumber _f 15.OUTER CASING for mniti<asi d�rells OR LIlVEIt eta linable
,1,e, ,L ()! f1i�+��f�=L f FROM TO DIAMEIEt[ �QQ�ER9 MfTERIAL
n n � ;d
ComparyName I&INNER CASING OR TUBING cotbermal doseddoo
2.Well Construction Permit#: `c� FROM TO DrA1 Wn R MCIt NM IMATEHiAL
List all applicabld well construction permits(i.e.UIC.County,Stale yonancq,eta) -- n- R-
t is r
3.Well Use(check well use): n it,
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Water Supply Well: 17.SCREEN
FROM I TO I DI NN= I SLOTS= I MHOOM83 I Off-ER-AL
❑Agricultural omulticipallPublic An ,S IL I(j ;n i t
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
n
Olndustrial/Commercial ❑Residential Water Supply(shared)
18.GROUT
❑hri ation r j ❑Wells>100,000GPD FROM To MATgRrAL MMACEMENTMETHOD&AMOUNr
Non-Water Supply Well: (} n z n / ./ .
❑Monitoring -Oltecovery . _ ft.- - '%
Injection Well: It. It.
❑Aquifer Recharge ❑GrotmdwawRemediation
19.SAND/GRAVE!.PACK a linable .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO EM1�.aac>anNTM�oD
❑Aquifer Test ❑StomiwaterDrainage R- n /J 6e,LvL
❑Experimental Technology ❑Subsidence Control it. n
❑Geothermal(Closed Loop) ❑Tracer 20:DRII.LING LOG attach additional sheets if
❑Gcotht rant(Hading/Cooling Rearm) ❑Other(explain under#21 Remarks) FROM TO DFSCREMON color,hardness,=Wruek sf¢q eta
g.6 IL
4.Date Well(s)Completed: j~ ?—'3w u m# n' ' `7 n w,c;;1y1
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5a.Well Location: ft. G('" r
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Facility/Owner Name Facility lD#(ifapplicable) R" ;," •, p ;• .
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Physiic�all Address,City,and rip p & ft. FEB B 4 2021
2L REMARKS
County Parcel Identification No.(PIN) 6fliCiiri:.l l !�i^�;y s.;F Uma
VYe C.JiSJk:i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Ce cation•
d vow �����
6.Is(are)thewell(s):.idermanent or oTemporary Sigmt=— ofQ tified well Contractor Date
Bystgnwgrhtsform,l hereby cer6fylhat thewell(s)was'(wem)cansiratedin accordance with
7.Is this a repair to an existing well: ❑Yes or IDivo 15A NCAC 02C.0100 or l5ANCAC 02C.0200 Well Construction Standards and that a"copy
Ifthis is a repair,fill out known well construction information and explain the nature ofdw ofd&record hasbeenprovided to the well owner.
repair under#21 remarks section or on the back of thisfornL
23.Site diagram or additional well details:
8.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 1 OW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box)-You may also attach additional pages ifnecessary.
drilled-
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.
For multiple wells list all depths ifd//ferent(=sample-3@200•and 2@100� ) Submit this GW-1 within 30 days of weIl completion per the following:
10.Static water level below top of casing: z- ( ) 24a. For AD Wells: Original form to Division of Water Resources (DWR),
Ifwater level U above casing,use••+• Information Processing Unit 1'617 MSC,Raleigh,NC 27699-1617
1L Borehole diameter. (hL) 24b.For Injeetion Wells:C ipy to DWR,Underground Injection Control(IUC)
j� Program,1636 MSC,Raleigh,1NC 27699-1636
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12.Well construction methods ° r `-a ""/ 24� Supply Wafter SD1Y and Open-Loop Geothermal Return Wells:Copy to the
(.e anger,rotary,cable,dices push,etc.) couety environmental health de3rartIIrcut ofthe county where installed
FOR WATER SUPPLY WELLS ONLY: I
24d.For Water Wells rodacin over 100 000 GPD:Copy to DWR,CCPCUA
n Peanut Pmgram,1611 MSC, etgh,NC 276 -16
13a Yield(gpm) Method of test: 7 Cs r
13b.Disinfection type: (Jr1� Amount:
Form GW-1 Nmth Carolina Departcut ofEnvironmental Quality-Division of WaterResources Revised 6-6-2018