GW1-2023-01755_Well Construction - GW1_20230223

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WELL CONSTRUCTION RECORD(GW.1) For Internal Use Only:
1.Well Contractor Information:
6c(ereAt f a�as 1r4R'5 •ATER TARES I
VVVV FEtOM TO DESCRIPTION
Well Contractor Name U ft. ft
Ll5`ls/-i- . ft. f
NC Well Contractor Certification Number 15;OYl FER.CASING'.for•in ieasis wells 01t INER-ill► cable
/1"it �S ��' i PU FROM R, TO � D1AiNETER�. �THfCIINFSS� MA��
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Company aur MR a ' / 16,'I CASING OR'T-,UB G. 'edttiermal'closed-loo
FROM To DLtl1�TER THIC1aVES3
2.Well Construction Permit#:5{'1/�22 MATERIAL
List all applicable well construction permits 0.a.UIC,County,State,Variance,ere.)
ft. ft. � in.3.Well Use(check well use):
1..SC EN P
Water Supply Well: FROM TO I DIAMETER SLOTSUM THICE ESS MATERIAL
:-Agricultural E)Municipal/Pbblic ft. ft. j In
Geothermal(Heating/Cooling Supply) okqpidential Water Supply(single)
IndustriaUCommercial [31tesidential Water Supply(shared) 16,.LR•UT
hTl atlon FROM TO TERIAI. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. GL
Monitoring Recovery fL ft.
Injection Well: ft, ft.
:.)Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL FA K. f:e Iicatile.
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test \ '``' [3Stormwater Drainage ft. tt �,
i:�
Experimental Technology j,: ,;r.` ElSubsidence Control
Geothermal(Closed Loop) OTracer 20.-DRIIjLrNQ LOGiatuts.clr dditignalsheets:ifaeeessa
FROM To DESCRn'TiON color,hardness saWrock acre etc
Geothermal(Heating( Ret»m Other(explain under#21 Remarks c5 G tt. :
(5 ft)�'/5� 7fL (X N- t
4.Date Well(s)Completed: ' I
WeB ID#
ft. ft. I�
So.Well Location:
v F
Facility/Owner a Facility ID#(ifoppticable) e—
1 v' 2023
ft. ft. FEB
•�r t yl
Physical Address,City,and Zip 0 . ft.
��/ 21. ARKS !' ` n.
County
Pascal Identification No,(PE)
_ '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(irwe0 field,one latflong is sufficient) 22.Certification:
35 y'70 01 J I N q0 38'23_ w
Signature4ofCordic—d Well Contractor Date
6.Is(ore)the wells)joPermauent or Temporary
By slgning_this form,I hereby certo that the weli(s)was(were)constructed in accordance
7.is this a repair to an existing well: ®Yes orI}Vo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200.Well Construction Standards and that a
Ijthis Is a repair,Jill out known well construction Information and explain the nature ajthe copy ojthis record has been provided to the well owner.
repair under 021 remarks section or on the back ofthls form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Lao eothcrmal Wells having the same You may use the back of this page to provide additional well site details or well
P'� construction details. You may also attach additional pages if necessary-
construction,only I GW-1 is needed.'indicate TOTAL NUMBER of wells
drilled: �-- SUBMITTAL INS EMIONS
9.Total well depth below land surfdce: 12.5 , (ft-) 24a. For Ali Wells: Submit this form within 30 days of completion of well
pop multipla wells list all depths ijd(/jereni(example-3 00"and 2®l00) construction to the following:,
10.Static water level below top of caslug:r' :1)0 (ft.) Division of Water�"Resources,Information Processing Unit,
Ijwaterlevel is above txastrig,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
24b.For Infection Wells: In addition to sending the form to the address in 24a
11.Borehole diameter: ( )
n above,also submit one copy of this form within 30 days of completion of well
•12.Well construction method. CJ construction to the following'.'
(i.e,auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground Injection Control Program,
1636 Mail SeMcl a Center,Raleigh,NC 276994636
FOR WATER SUPPLY WELLS ONLY:
�e 1- 24c, or"later SuDDiy&rInlection Wells: In a m within 30 days ddition Co sending the form to
13a.Yield(gpm)_ Method of test: the address(es) above, also submit one copy of this for
V✓' �P/r Y\.C_ Amount: S completion of well construction to the county health department of the county
136.Disinfection type: - ` where constructed.
Farm OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016