GW1-2023-01681_Well Construction - GW1_20230214

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
51ju, Adams 14:WATERZONEs
Well Contractor ame FROM TO DESCRIPTION
W 0 ft
NC Well Contractor CertificationtNumber f1 ' IS:OGl'TER CASING O&muld-insied`wella);bI11 IlYER:(itavoliaabltl
0 1 W.it �� Lu� FROM TO D"WETER THICKNESS MATERIAL
r 1 ft Oft. In.
Company Name
�w O 3 — a 1 I 16 EAS1Nl:.Dg.7UBIN-4 euthermal;elaed�oo r 3 :
2.Well Construction Permit#: O FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(1,e.UIC,Count),,State, Variance.etc.) R. ft. in.
3.Well Use(check well use): ft. 1t in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) g• n•
❑lndustrial/Conunercial ❑Residential Water Supply(shared) is GROUT
OhTi ation ❑Wells>100,000 GPD FROM TO MATERIAL I EMPIACEMRF METHOD&AMOUNT-
Non-Water Supply Well: Zb Q
❑Monitoring ❑Recovery M R.
Infection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
f:19:S . Rek -P1 cbCe 3
❑Aquifer Storage and Recovery ❑Salinity Barrier I FROM I TO I MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage fL fL
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 1t1..DRILLIINGI:OG strict,addittonal sheerer if riecesaa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardnesj6 wiVrock type,,ntin sty,etc
0 ft. 010 ft.
4.Date Well(s)Completed: 1'� Well ID# Q Z0 ft- t00 n- 9
5'a`Well Loc0'.11.n /1 ' � ' ft. 10 0 h G
wav1ck ( yr-roli 61 V.
Facility/Owner Name Facility ID#(if applicable) h' M
l G qq r ettydfr Lake d r W d le W ft. ft.
Ph( a kys�iccall�Adddress,City,and Zip ft. R'
W r-
21 REMARKS.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 74
(ifweil seta,one tastong is sumclen) 22.Cer' tion
6.Is(are)the well(s): dpermanent or ❑Temporary Signature of C red Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: Oyes or Ao 1 SA NCAC 01C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a copy
Ifthis is a repair,fill out known 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:
Ynii may ime the hack of this nnae M nrnvide additinnal well ennctntctinn info
U ..E ,,.f ells (add'See Over'in Remarks Box).You may also attach additional pages ifnecessary.
construction,only i GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: N 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Z o D (ft-) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@100'and IQ100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: �b (ft.)
Ifwater level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
1414>\,tct, m('17Foo_1414
12.Well construction method: 4_11- trd�al'I 24c.For Water Supely and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environments ea department 0 e county w ere costaffW
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13s.Yield(gpm) O Method of test: 0W
•• '' Permit Program,1611 MSC,Raleigh,NC 27699- 611
13b.Disinfection type: Amount: 2
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018