GW1-2023-01683_Well Construction - GW1_20230214

;;rf LL,CONSTRUCT10N RECORD (GW-1) For Internal Use Only:
1.Well Contractor Woe oration:
�G �(7() .Q 4.WATER ZONES
Well Contractor Name ntom TO uscitiP'RoN
2-$1 FEB 1 202; °b ft' S �-
NC Well Contractor Certification Number 15.OUTER CASING tar welts OR Idl'iER
mom To DtAnsE'A TIEUCKNESs MATUUAL
rah �b0 ft. IL ter.
Company Name 2 16 K CASING OR TUBING d md-0
2.Well Construction Permit#: �4 W— U 7 FROM I TO DIAMET M TMCK1rM I MAT6RIM.
List all applicable well constriction permits(l.e.WC,Coum D,.State,Variance•etc.) ft. 2 z oft. In. (C.
3.Well Use(check well rase): ft. ft, in.
Water Supply Weil: 17.SCREEN
FROM TO 1 DIAMETER SLOT SIZE THICKNESS T MATERIAL
Agricultural unicipaUPublic ft. % la.
Geothermal(HeathwCooling Supply) ORMWential Water Supply(single) fL IL la
Industrial/Commercial C)Rcsidcutial Water Supply(sbared) It GROUT
Irrization FROM I TO LWPtAC UMOD&AAfOUNT
Non-Water Supply Well: 0ft 22� ft' Gi i1 Q
Monitoring ORcwvery ft, ft, 1h Ptil
I(Czeathetmal
ce n el:quifer Recharge ©GroundwaterRemediation19.SAND/GAAVELPACK f abHZ
quifer Storage and Recovery Salinity Barrier FROM TO MA ERDa. EMPLAC6ME:NTMETHOD
quifer Test [3Stormwater Drainagexperimental TechnologySubsidence Controleothermal(Closed Loop) Tracer 20.DR/LLIIVG LOG attach additional sheets U
FROTH TO DFSCRiPt4ChN(color� H—sawrockt a oil: ate.)
satin Cooling Return) Other(explain under#21 Remarks ZZ0 ft. 3 D 0 ft.
4.Date Well(s)Completed: 4 -2 Z Well M# ft- ft•
ses.w it LacatiOp'
ft. ft.
��� L'�(D� ft. ft.
Facility/Owner Names pp Facitity ID#(if applicable) ft. ft.5 501 61uc Sa9ti (/1� ft. ft.
Physical City,and Zip ft• ft
I a ,� at.REMARKS
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutea/seconds or decimal degrees:
(ifwell field,one tattlong is sufficient) 22.Certification: f
N W
6.la(are)the well(s)dPermanent or Temporary Signature of cd Well Con for Date
By signing this form, I hereby certify,thra'the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: arYes or [3No with 15A NCAC 02C.0100 or 15A NCAC 01C.0100 Well Cowmection Standards and that a
If this is a repair,Jill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#11 remarks section or an the back of tk v form.
23:Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the some You may use the batik of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also a?ta(,h additional pages if necessary.
drilled: r ___ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 b (fL) 24a. For All Was Submit this tbrm within 30 days of completion of well
For multiple wells list all depths ifdt fferent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: () (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: + _(ia.) Ub.For Infection Wells: In addition to sending the form to the address in 24a
+0 V- above:, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(ia auger,rotary,cable,direct pleb,
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
l' 1636 Mall Service CcaUr,Raletgb,NC 27699-1636
13a.Yield(gpm) S Method of teat: a`^ 24c.For Water Supply& iniectlo;g_tVells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: h Amount: 2 completion of well construction to the county health department of the county
where constructed