GW1-2023-01692_Well Construction - GW1_20230214

W. LL CONSTRUCTION RECO _ (GW-I) ForIutemalUse Only:
1.Well Contractor-Information:
• S ,:
Well Contractor Name — - s y '14.WATER ZONES
I
. gym• r `FROM TO DES ON
UvfL 3&�
FEBg it
NC Well Co D g ntractor Certification Number r � 2Itn 23 f
1S.OUTER CASING for mold-cased wells OR LINER rf a Gable
fjyrI� -y �i� In _a i •yl _ U .FROM TO DIAMETER TffiCRNESS MATERIAL
ft Company Name s f6
a1d; L JL: m.
16.INNER CASING ORTUBING eothermal closed-loo
Li 2.Well Construction Permit#: 5 Q Z FROM TO DIAMETER TSICIQVESg 1NArERIAL List all applicable well construction permits 0A WC,County,State,Variance,eta) ,F , ft 51 ft Ch Ir't✓
!hr
3.Well Use(check well use): & fG in
Water Supply Well: 7.SCREEN p
❑Agricultural FROM TO DIAMETER SLOT SIZE 7MCKNESS RL&L MATE
❑Mtmicipal/Public ft ft _ 110.
❑Geothermal(Heating/Cooling Supply) idential Water Supply(single)
❑lndustrial/Commercial ft: ft in'
esidential'Water Supply(shared) IS.GROUT p
❑Irri lion ❑Wells>100000GPD FROM To TERiAI EMPLACEMENTMETI;OD&AMOUNT
Non-Water Supply Well: V ft SQ ft. `
❑Monitoring ❑Recovery
Injection Well: fe ft: ,Yv'tt
❑Aquifer Recharge ❑Groundwater Remediation ft ft
❑Aquifer Storage and Recovery ❑Salinity Barrier nD
RAVELPACK rta liable
TO MATERLAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft
❑Experimental Technology 4Subsidence Control fc
❑Cieotheimal(Closed Loop) ❑Tracer 20 RILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DEstlION color,hardness soiVmek rn s eta
ft ft �; �•
ID YL Gt Cd
4.Date Wells)Completed: - Z?_ 23 Well ID# ft. f't •--'
5a.Well Location: ft ft. 11
A r1�, ati C�s�,-rt��. cL C. f� —�
Facility/Owner Name FacilityIN(ifapplicable) ft. K
-- as+ eud Rd - �w � � t C-0 -'ft ft
l S�
Physical Address,City,and Zip ft
A�ck j Ate W` 21.RElYlAItI{S,f`
county
Pastel Identification No.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient)
22.Certif!ca'on:
6.Is(are)the well(s): [3PermaDent or ❑Temporary 79) Signatudr o CeiiMdd•We l Conl actor ,` Date
:Bysigningthisform,thereby certify tha!the wells)was(were)constructed in accordance with
7.IS this a repair to an existing well: ❑Yes or 1551 i*SA NCAC 02C:0100-o"liANCAC 02C:0200 Weft Construction Standards and that a copy
If this is a repair,fill out Imoun well construction information and explain the nature of the ethis record has been provided to the well owner.
repair under 021 remarks section or on the back ofthisform.
23.Bite diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW I is needed Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled:
//� n 1 24.SUBMITTAL WSTRU.I70NS
9.Total well depth below land surface: � IP(� ft 1
For multiple we As list all depths fdderent(aample-3@200'amd 2©100) ( ) Submit this GW-1 within 30 days Of well completion per the following:
D
10.Static water level below top of casing. 1 (ft) 24a•_For All Wells: Original foim,to Division of Water Resources (DWR), '
f water level is above casing,*.use Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: tD •(in,) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
ll Program,1636 MSC,Raleigh,NC 27699-1636
12.Welt construction method:_R o T&I I,_•f/cv� _
i.
(Le.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loon Geothermal Return Wells:Copy to the
county environmental health deparbnent of the county where installed
FOR WATER SUPPLY WELLS ONLY: I
24d.For Water Wells urodaciae I ver 100 000 GPD•Copy to DWR,CCPCUA
13a.Yield(gpm) Q(� Method of test C( 6,4 Permit Program,1611 MSC,Raleigh,NC 27699-1611 a
_ 1
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department ofEnvimnmental Quality-Division of Water Resources
Revised 6.6-2018