GW1-2023-01688_Well Construction - GW1_20230214

SELL-CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Inforrmatiion:
I'm .
" FROM TO DESCRIPTION
Well Contractor Nam Ft d 7 � 2013 tt ) R.
a l 1 A 1 ft. ft-
NC
NC Well ContractorCertificatio Number
f• FROM TO DIAMETER THICKNESS MATERIAL
D ft. 1t. in. V
Company Name J
��'' /� 7���/ 16:1NNER CASING.OR TuBI1V.03 eothermal el�edao.°'
2.Well Construction Permit#: CCU W 7/r�4 lV !iP 'l, FROM TO DIAMETER I TMCV_NXSS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Slate, Variance,etc.) ft. ft. in.
3.Well Use(check well use): tt. tt in.
Water Supply Well: 11,SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑Aericultuml C1MunicinallAthlir. +,t•
❑Geothermal(Heating/Cooling Supply) iResidential Water Supply(single) it. tt in.
❑Industrial/Commereial ❑Residential Water Supply(shared)
OIrrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: R• z® i2i4
❑Monitoring ❑Recovery ft. ft.
Injection Well: fL fL
❑Aquifer Recharge ❑Groundwater Remediation
ClAaniferCtnraoe.andRrrnvery ncat;n;wRa..;.� 9 ANA/liRA L"l'AGIC,lfa fable
❑Aquifer Test ❑Stormwater Drainage ft fL
❑Experimental Technology ❑Subsidence Control ft. tt.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING I t7G sittech addi$o aai.eheets if necnss
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardnes soiVrock n size,eta
ft. ct
4.Date Well(s)Completed: � - Well ID# h A ft• ft r+ ,
C
5a Well Ikocation: I
tt. %
Facility/Owner Name Facility ID#(if applicable) ft• ft
d
.2 15 R. ft.
Ph Address,City,and Zip ft ft.
C- 1 %l L 53g 1 21.RFMARK4
County Parcel Identification No.(PIN)
5b.Latitude and longitude In decrees/minutes/seennds nr rlerimal Anuronc•
(ifwetl field,one lat/long is sufficient) Y 22.C tifieation:
N w � •� �r�
6.Is(are)the well(s): 'Permanent or ❑Temporary true of Certified We C ctor Date ,
By signing this form,I here certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yea or o ISA NCAC 01C.0100 or JSA NCAC 01C.0200 Well Construction Standards and that a copy
Ythir 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:
.u. .,�..Y.u.. .., u, %_tuseu-Luup veutnermai wens naving ute same �u��� u, �a�n��""'Yago w y,uv,uc AuuMund,Well construction info
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:_I 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 p10 (ft.
For multiple wells list all depths if different(example-3Q200'and 2®100') ) Submit this GW-1 within 30 days of well completion per the following:
2' C7 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing:
If water level is above casing,use"+' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: Copy to DWR,Underground Injection Control(IUC)
— t'ru�.a.,,, iu�u,v,ui.,aa,e,gn,,vt,troYv-loon
12.Well construction method: rD �l I' 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.)
county environmental health department o e county where mstall
FOR WATER SUPPLY WELLS ONLY: 14d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: b Jo / Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: �� Amount: