GW1-2023-01505_Well Construction - GW1_20230209

WELL CONSTRUCTION RECORD(GW71) For Internal Use Only:.
1.Well Contractor Information-. r
WellContractmName FROM TO DESCREMON
lz it_ W
A-i-7,2-- k '391 T-C n It
NC Well Contractor CeruficationNombu
i5.0UTERCASING formNtl�nsed�vells ORLINER da ble
/� '42 Li l t. ✓ FROM " DM AMUR macro s MATERIAL
It. M
CompanyNamc
L�.�p 16.INNER CASING OR TUBING eothermal dosed-too
2.Well Construction Permit#: 1 19 f iL FROM 110 1 DIAniLTER I TffiCI NM I MATERIAL
List all applicable well construction permits(r.e:LUC.County.State.Variance,etc.) ft. f in. 1
3.Well Use(check well use): IL
Water SupplyWell: 17.SCREEN
FROM TO BLUM = SWTSM T11IC IMS MATERIAL
❑Agrictiltulal ❑Mutlicipal/Pmblic iW
ft fL f,f iv d '
❑Geothermal(Heating(Cooling Supply) ❑Residential Water Supply(single) ft. IL
❑lndustrial/Commcmial pReddential Water Supply(shared) 1&GROUT
❑ ri ation r• ❑Wells>100,000 GPD FROM Ta AtVrEHUL EMRLAMEENfMETHOD&AMOUNT
Non-Water Supply Well: ) 7— d
❑Monitoring ORecovery - - It. M -
Injection-Well: n
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL E M ACEMMMETHOD
❑Aquifer Test ❑Stormwater Drainage n- � it.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRII.LINGLOG attach additionalsheetsifn
❑Geothermal(He9mg/Cooling Return) ❑Other(explain under 1121 Remarks) FROM I TO DFSCRI]MON color,hardness,mOhoc& shw etc
tl_ rl6 iti
4.Date Well(s)Completed: — Z Well W# 2.� m 6-4,4141
58.Well
�T lion: "L U
a(� � � �� •L L ft.
Facility/Owner Name FacilityM#(ifapplicable) ft
dam . ztl 4_ fL ft
_ �ir - Z Z tr. % �_C b� J 1. 3
Physical Address,City,and Zip
2L REMARNS
county Parcel Identification NZ.(Ply ,Di `o'v�l
5b.Latitude and longitude in degrees(minutes/seconds or decimal degrees: r9
(dwell field,one Wong is sufficient) 22.C cation:
R -
6.ls(aie)die,well(s): Bgermanent or ❑Temporary Sig�ta.ofcatifiodWoucoridi= Date
Bys,&ing thisform,I hereby curt ftthat the well(s)was(were)constructed in accordance with
7.Is this a repair to an eiristing well: ❑Yes or &Nd—r 15ANCAC 02C.o100 orISANCAC 02C_0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out(mown well construction information and explain the nalure ofthe of this record has been provided to,the well oxmer.
repair ceder#21 remarla section or on the back of this form.
23.Site diagram or additional well details:
8.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 OW--1 is needed Indicate TOTAL NUMBER of wells (add,See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled-- 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ��� (R•) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdi1Teraw(example-3Q200'and2Qa 100) 1
10.Static water level below top of casing: -j ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
I10.Stater tic a above casing,use o Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1# 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter. Cm-) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: n'b WJ)-- r� 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(-anger,rotary,cable,du%:ct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLrY�WELLS ONLY: 24d.For Water Wells rodn over 100 000 GPD:Copy to DWR,CCPCUA
13n.Yield(gpm) 1 j ��/'/ �AMethod of test:�u y Perm t Program,1611 C,lWel C 2-1 99-1611
13b.Disinfection type:°""•�l Amount:
Form GW-1 North Carolina Departarent oflinvironmmtal Quality-Division of Water Resources Revised 6-6-2018