GW1-2023-01741_Well Construction - GW1_20230213

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1,Well Contractor Information:
�.� W t�a V 14.FROM\VATER ZONES --
t O>f TO DESCRIPTION
well Contractor Name � ft. O ft. f
3 1 _� ft. ft.
NC Well Contractor Ccrrt...ii fiicatio---n Number 15.OUTER CASING for multirascd wells OR LINER if a lica111
FRO?( TO
DLt11E:TSR "PHICK�IESS �LAT7:A IAI.
ft. U© ft. In. I Ll O / -C
Company Name 16.INNER CASING OR TUBING(geothermal closed-loopl
q� FROM 'rcr DIAMETER 77nCKYESS \1ATEitV.1.
2.Well Construction Permit#: PwS Irj� � f 007� ft. tt. in
List all appticable well construction permits(i.e. UiC,Counn•,.State,Variance,etc.)
ft. ft. In.
3.Well Use(check well use): -
11.SCREEN
Water Supply Well: FROM TO n1AMETER SLOT Sill-, THICKNESS MATERIAL, _
❑Agricultural ❑h4umci aUPublic J.� ft R• ;I, In. �-.�
t7Fieothetmai(Ileating/Cooling Supply) csidi!ual Water Supply(single) ft ft.
❑IndustriaUCOMIICTcial ❑Residential(later Supply(shared) 18.GROUT -
❑Wells> I00,000 GPD FROM vO �tAT1:R1A1. E.MPLACEmEVT METHOD 6 AMOUNT
Olrti anon ft. aO fr.
Non-Water Supply Weil: S�
7Monitoring ❑Recovery ft ft.
Injection Well: ft. ft.
C3Aquifer Recharge ❑Groundwater Remediation 19.SANU/GRA\'EL PACK if a�advabie
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL ESiPf ACENE\?METHOD
UA ❑ c Stormwatcr Drainage ft. Q ft. 2uifer Test
q eD L-1
_
❑Experimental Technology ❑Subsidence Control ft. ft.
C]Cmothenrrai(Closed Loop) ❑Tracer 20.DRtLLiNG LOG attach additional sheets U necessary)
FROM TO DFSCRiIP'CIOV br.hard rns,wWrocats t, lnd etc.
(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ' O tt �t
IL
4.Date Well(s)Completed:� •� Well[Di# 4 0 ft' -
ft. ft.
5a.Well Location: - -
�'� n ft.
I;aeilitvOwnerN ne Facility ID#(ifapplicable)
O ft. ft.
-71 Z (`...1 o u ces;mac dc, t�]t�sF,:^S? h N.C ft. ft.
Physical Address,City,and"Lip
a� 9 21.RESIARKS _
County Parcel Identification No.0"IN- 1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(if well field,one lit/long is sufficient) 22.Certification:
35 bug 3y� N- . 160�8 W _
Stgnatu a of Certified L1'e11 ontraetoi Date
6.Is(are)the well(s): �rmanent or ❑Temporary
By signing this fornJ I herehv certii v that the weil(s)u'as(were)constructed in accordance owl,
7.Is this a repair to an existing well: ❑Yes or 06%w' 1 SA NCAC 01C.0100 or 1 SA NCAC 02C.0200(Pell Construction Standards and that a cope
!(this is a repair,fill out knowm well corudveJion inforniation nrui explain the nature of the
of this record has been provided to the well owner.
repair under 421 remark.seclior or on the back of(his form 23.Site diagram or additional well details:
8.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.T tal well depth below land surface: 80 (ff) Submit this GW-1 within 30 days of well completion per the following:
For multiple we/Lr 1W all depths if different(evantple-3(dj200'and 2(g1100•)
�1 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Stack water level below top of casing: �..L (ft•) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
tf warer level is about casing,use'"i"i r i
1 24b.For in)ectioD Wells: Copy to DWR.Underground Injection Control(IUC)
IL Borehole diameter: Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ` n\to P-bT l C 24c.For Water rSSu�I•and Open-Loop Geothermal Return R'Ll11-Copy to the
(I,auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,161 1 MSC,Raleigh,NC 2 7699-1 6 1 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: k Amount; 3 C1 Z
Division of Water Resources Revised 6 6.2018
Forth 6W_1 North Carolina Department of Environmental Quality•