GW1-2023-01870_Well Construction - GW1_20230222

^\` For Internal Use Only:
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14.WATER ZONES I I
AJ
- FROM TO DESCRIPTION
D ". .9;5 it. 6 Po-
175It 0Dft 4yeVU-1
15,OUTER CASING forni0ti-cased yells ORLIKER ifa livable
FROM TO DIAMETER TH CENESS MATERIAL
---- --_ ------ --I +1 ft. � ft 6 I a I in. i5VA-9-p I PV&
/��� 16.INNM CASING OR TUBING eotherm�l closed-loop)
-VO(30 FROM TO DL1d=R I TMCIGMS I 114ATL+RIAL
LW all opphcabls well construction permits(Ie.WC,County,State,parlance,eta) M it in.
3.Well Use(check well use): fi: ft in.
Water Supply Well: 17.SCREEN
TROM TO DIAMETER SLOT SIZE TIUCIQYESS MATERAAT.
❑Agricultural cs ❑Municipal/Public g, ft. in.
❑Geothermal(Heating/Cooling Supply) esldential-Water Supply(single) it. it. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM I TO MATERIAT EMPLACEMENTATETHOD&AMOUNT
Non-WaterSupplyWell: 0
ft ft.
❑Monitoring ElRgcove it ft.
Injection Well:
ft ft
❑Aquifer Recharge F t B 2 2 Vndwater Remediation 19 SANDIGRAVEL PACK[rf a linable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To I MATERIAL PUPLACEMENTMETHOD
❑Aquifer Test in;%ii=e:aa:? ?r;,:[ingD gkt rDrainage ft
v+i Qi50G
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.3)RILLVGLOG attach additional sheetsifnecessa
❑Geothermal(Heatmg/Cooling Rettmm) ❑Other(explain under#21 Remarks) FROM To DESCRPTION color,hordncm,soVrvrk a ain sire,etc
M1 ft y ft. ? 1 d- t�f M 5
4.Date Wells)Completed: 6 �^ Well ID# D' 61 ft v �q eJq 4.
K% to I`l/►ar f ti.� ( i ft ft t. /
5a.Well Location: q
Phone#�. 3��-��3�(
&- \-3e ve 50l{ems.C440d-C4 it w it �„� a< L�� �s t fr'►* � '
Faciility/Owner-Na) p� [m° FacilityM#(ff applicable) ft ft ` o•
I!X2 2 c��/\a✓X!> 1 �y (t�E�®'8 N d ft.. ft
Physical Adare�spycity:and zip
/
ft ft.
_ C S i,A Pa & 21.REMARKS. - i (' ' f
County Parcel Identification No.(PIN) e.el•e r` �� _ �� ©�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: L�
(ifwell field,one lat/longis sufficient) 22.Certificati n:
6.Is(are)the well(s): �rmanent or ❑Temporary re of Certified Well Contractor Date
By signing thisform,I hereby rertify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or W, 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,frll out]mown well construction information and explain the nature of the of this record has been provided to the well owner.
repairunder#21 remarkssectionoron the back ofthisform.
23.Site diagram or additionalwell details:
8.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-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarlcs Box).You may also attach additional pages Enecessary.
drilled: I24.SU13M rrAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths tl'diferent(example-3(n]2 'and 2@100)
S® 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft-)
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwater level is above Casing,use"t'
XI.Borehole diameter: (in.)
Bit Off: 6, b9'J tab.For Injection Wells: Copy to DWR,Underground Injection Control(1IJQ
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie.auger,rotary,cable,direct push,eto.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: J� 24d.For Water Wells producing over 100,000 GPD:Copy.to-DWR;,CCPCUA
13a.Yield(gpm) Method of test: 14' A' Permit Program,1611 MSC,Raleigb,NC 27699-I611 f"�
13b.Disinfection type_ 70%HTH OZ DA Amount _ VISITED:
-pg s- It ys 1:
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