GW1-2023-01504_Well Construction - GW1_20230209

i
WELL.CONSTRUCTION RECORD(GW 1) For Internal Use Only.
1.Well Contractor Information:
i 3 V' + �/� 4-WATER ZONES
Well ConttactorNatne FBOM TO DFSCBiPTiOx
NC Well Coutractor CettificalionNomber M OUTER CASING formuld-c6ed wells ORLINER f
t ' �!V � `^ 6"V'� FROM TO DIAMETER MHCKNM MATERIAL
IL n in-
CompanyName
16.INNER CASING OR TUBING eotitermd dosed-too' '
2.Well Construction Permit#: 7 FROM TO DIAMETER THICKNESS MATF�rAI.
List all applicabld well canslrttction permits(t-e.UIC.County,State,Varian eta) fL qS fL t t in - De
t
3.Well Use(check well use): S-1 B- � � fL !i in. t i rl
Water Supply Well: 17.SCREEN
FROM TO DL hmm SLOT SIZE TMCKNM MATERIAL
OAgricultmai Municipal/Public �/tr. fL •r, in. G
-34
❑Geothermal(Heating(Cooling Supply) ❑Residential Water Supply(single) fL M h
❑hrdustrial/Commercial _ residential Water Supply(shared) 1&GROUT
❑Irri ation ❑Wells>100,000GPD FROM TO MA1ERrAL EMPIACEB7ENTM=OD&AMOUNT
Non-Water Supply Well: /3 n 24 fL
❑Monitoring- - ❑Recovery _tL - 1L
Injection Well: is IL
❑Aquifer Recharge OGroundwater Remediation
19_SAND/GRAVELPACK rifo rmble
❑Aquifer Storage and Recovery ❑Salinky Eairier FROM TO MAI=d&L I ENTLACEn't@1TMelHOD
❑Aquifer Test OStormwater Drainage ft. n
❑Expemlental Technology ❑Subsidence Control B- IL
OGeothenmal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Beta m) ❑Other(explain under#21 Remarks) FROM TO DFst RipTlox tutor traran . solt/roe[c sl>r,etc
4:Date Well(s)Completed: Well ID#-. r✓ fL a
5a.Well Location:,, fL ;tt, , 1
Facility/OwnerName Facility ID#(ifapplicable) � fL 74
ft. fL FEB 1J 9 2023
Physical Addnss.City.and Zip
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees'/minutes/seconds or decimal degrees: :y 6
on(if well field, e Wong is sufficient) / 22.Ce CatioD:' 3 / e-
1 w
6.Is(are)the well(s): F anent or ❑Temporary Signature of Certified well Contractor Date
Bysfgning thisform.l hereby ceWfy that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or L hri ISA NCAC 01C-0100 or 15A NCAC 02C.0200 Well Conshucrion Standards and that a copy
Ifthis is a repair,fll out known well construction information and explain the nature ofthe ofthis record has been provided to the melt owner.
repair under d21 remarks section or on the back of this form., f
23.Site diagram or additional well details:
&For GeoprobdDPT 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 GW 1'is needed: Indicate TOTAL NUMBER of wells (add'See Over'in Remadss Box)-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 mulhple wells list all depths ifdifferent(example-3@200'and 2@100)
24a:For-All'Wells:-Original-form-to-Division of Water Resources (DWR),.
i6.Static water level below top of casing: -Z (ft) Information Processing Uriit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above easing,tine"+" -- -
G i i �) :241L For Infection Wells:_Copy to DWR,.Underground Injection Control(1U
11:Borehole,diameterv-
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: j y' l/1 ,24c.For Water Supply and Opeo-L000 Geothermal Return Wells:Cop_y to the'
(r a auger;rotary,cable,direct push etc) 'heal ty-*hdm installed
county -
FOR WATER SUPPLY WELLS ONLY: , '24d.,For.Water Wells rode z over 100.000 GPD:Copy to DWR,CCPCUA
Get 'Pennit Program,-1 11 MSC; eigl, C 27, 9=1611
13a.Yield(gpm) ii Method
-of test: �l ;
13b.Disinfection type: �i1 I � y-Amount
1
Form GW-1. " North Carolina DepaAment ofEaviraffiental Quality-Division of WaterR.Ii. _ Revised 6-6-2018