GW1-2023-01625_Well Construction - GW1_20230214

WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor Information:
.,I t7�' PGt7�'�, ' `r i..,-,�".�� �• ',t4' "P1�tZj;'NE � ' } v� �a���1:,i r i
Well ContractorNameROM TO DESCRIPTION
�) FEBF 2023
NC Well Contractor Certification Number
()� (9 W�
G�l�0 �JO�' etl ( ' �f' ��' titUhl XU uaueiaiax �nitAn6lJ nlH,rtuAil
Company Name IV.
2.Well Construction Permit#: G 41- 06 7 V`I FROM TO DLIMEIZR TIUCSNM MA ERUL J
List all applicable well construction permits(Le.UIC.County,State,Va dla's,•etc.) ft n• IM
3.Well Use(check well use): n' n' im
Water.SupplyWell:
FROM TO,:.:.. DIAMETRR I stor9= nucK am I MATERIAL
❑Agricultural ❑ffMunicipab'Public ft ft. In.
Ut;eothermat(t•teatinglUooiing Supply) IZLAesidenual Water Supply(single) tq, In.
❑Industrial/Commemial ❑Residential Water Supply(shared) x . F ,r�u 1 � 7. r ,« r 5
01tristation • ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
❑Monitoring ❑Recovery 1L R.
Injection Well:
❑Aquifer Recharge OGrotmdwater Remediation
❑Aquifer Storage and Recovery OSalinity Barrie FROM I To 1. MATERIAL I EMPLACEMENT METHOD
:..
❑Aquife'l'eat ❑Jttnmwattr Jhainage ;`-
❑Experimental Technology ❑Subsidence Control it. R.
❑Geothermal(Closed Loop) ❑Tracer = 00 .ddtifiou ' `'iftiis
❑Geothermal (Heating/Cooling Return ❑Other lain under#21 Remarks FROM TO DESCRIPTIO color bardness.soWrocn fta,gralm size etc.
(0 30 ft- -54Z kt
4.Date Well(s)Completed: Zd a Z Well ID#A0' `30 tt. 1, tt Q
5a.Well Location: %
I A I I
Facility/Owner Name Facility 1Dli(if applicable)
Physical Address,City,and Zip irk 7 are Q / ft. ft.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
N W
6.Ware)the well(s): 6ermanent or ❑Temporary Signature f Ccrtified Well Contractor Date
By signing this form,I hereby certify that the wells)was(wen)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or S40 15A NCAC 02C.0100 or IJA NCAC 02C'.0200 Well Construction Standards and that a copy
If this is a repair,fl/I out blown well construction information and explain the nature of the of this record has been provided to the well.owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
a > . r-.,.- r, mar rt .-a r .•__..__�_,a._n_L_. __.�__-_- You may use the hack of this nave to nrnvide.ndditinnal orr11 ermatn,ctinn info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells """ '` "• ' "" ""`°''�^t '�""."y OIpU O,w�,l OLLUl4Vl 01 Y4gW L uWl play.
drilled:1 24.SU13MMAL INSTRUCTIONS
9.Total well depth below land surface: (ft.)
For multiple wells list all depths ifdtiffavni(example-3Q200'and 2@1000 Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: Zo (ft.) 24a. For All Wells: Original focal to Division of Water Resources (DWR),
Ifwnter level is above casing,use'.+.. Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in,) a 24b.For Injection Wells: Copy to DWI;,Underground Injection Control(IUC)
Prnoram 161l T,fCl` RalAiaV� Nr'77F00_1/;1R
12.Well construction method: Cl i f' r0�A rx 24c.For Water Supplerand Open-LoopGeothermal Return Wells:Copy to the
(i.e.saga,rotary,cable,direct push,etc.) county environmental health(ICpartI31Mt 01 the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Co to D
f t gram, 611 MSC,Raleigh, C 2 6 1 11 Copy CCPCUA
Permi
13s.Yield(gpm) � Method of test: �0�
13b.Disinfection type: Amount: j!!s'f•a'i.N
Form U W-1 North t arolma Department of tnvuonmentai Quality-Divtsion of Water Resources Revuad 6-6-20I R