GW1-2023-01531_Well Construction - GW1_20230218

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor Information:nf
-7-, a± ( -�.f, 1 f1 tk-ne `/ 14.FROM TER ZONES -.
tt ` "�1 t7 r FROM TO DESCRIPTION'7
Well Contractor Name r`flu ft. 8o G. t1 ft. f � MP� �}
3 1�$-�1 ft. ft. 1
NC Well Contractor Certification Number 15.OUTER CASING(for lulti-eased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS _MA TER AAl.
Co c Company y / ft. fi4 0 rt. in. y 0 Pt-(
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM 'rcr DIAMETER THICKNESS MATEitV.l,
2.Well Construction Permit#: PW��0 d+ 1�7� ft. ft, in.
List all applicable well construction permits(i.e. U/C,County,.State,Variance,etc.) -
_
ft. rt. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT THICKNESS MATERIAL _
❑Agricultural ❑Muntci .1Public J,,iO ft. tilio rt. in. /c. 4 0 -
°Geothermal(Heating/Cooling Supply) csidential Water Supply(single) ft. ft. in.
OIndustriaUC:otmnercial ❑Residential Water Supply(shared) iS.GROUT _
.°Wells> 100,000 GPI) FROM '4O MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Wate ) (t aO It. - IL r�(/�'
Non-Water Supply Well: / _ S�
i7Monitoring ❑Recovery ft ft.
Injection Well: ft. ft.
°Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Test ; ❑Stormwatcr Drainage raa ft. gQ ft. #-A... ! `1v1
❑Experimental Technology ❑Subsidence Control ft. ft.
OGtxathennal(Closed Loop) ❑Tracer 20.DRILLiNG LOG(attach additional sheets U necessary)
FROM TO DESCRIPTION( .hardiness,so rainil/rock type. dye,etc.)
°Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ' ft. ki O rt. 4-efi 4. ttS py �
4.Date Well(s)Completed: /2-7-2 3 Well ID# 40 ILg0 R. G ir47 i'2 d, �' '""S
ft. n.
5a.Well Location: -- -
eficeJ H (c-k- _ ft. ft.
I.acihty Owner Natte Facility ID#(if applicable)
o G ft. ft. -t� i 1 n23
Li"71 ] G!a t,;Cets;Pc- dC' (kP\SC►fIST h N. ft. ft.
Physical Address,City,and Zip ; 1_'r.-
PI:TsT a79 21.REMARKS _
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cert !cation:
35, btq 3.yA, N- i -/ , 1603. 1 w ri-.2-7=23
Stgnatu a of Unified Well ontractor Date
6.Is(are)the well(s): Prgmanent or ❑Temporary
By signing this form,I hereby certify that the well(s)was(wore/constructed in accordance wail
7.Is this a repair to an existing well: DYes or jayAit)^-' 1 SA NCAC 02C.0/00 or 1 SA NCAC 02C.0200 Well Construction Standards and that a cop;
If-this is a repair,fill out blown well corudveJion information and explain the nature of the
of this record has been provided to the well owner.
repair under#21 remaria section or on the back of this Joan 23.Site diagram or additional well details:
8.For Geoprobc/DPT or Closed-Loop Geothermal Wells having the same You may use the hack of this page to provide additional well construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'Sec Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: Q 24.SUBMITTAL INSTRUCTIONS
9.T tal well depth below land surface: V 0 (ft.) Submit this GW-i within 30 days of well completion per the following:
For rr�ulriple wells list alldepths if different(example-3(a)2(JO'and 2(al J 00')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: J.1. (ft') Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
if water level is above casing,use"i" 1 t t
6"Ti._ tire) 24h.For injection Wells: Copy to DWR.Underground Injection Control MCA11.Borehole diameter: Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: lryl LID P 'T (' 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
0 e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 2 7699-1 6 1 1
13a.Yield(gpm) AIL.) Method of test:
13b.Disinfection type:C1,lt VIA..... Amount: 3 Q Z
,,
Farm GW_i North Carolina Department of Envirotunental Quality-Division of Water Resources Revised 6-6-2018