GW1-2023-01884_Well Construction - GW1_20230222

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WELL CONSTRUCTION RECO (GW_1) For Internal Use Only:
1.Well Contractor-Information:
�c+ P I
J o In Q G '14.WATER ZONES 1 I• 1
Well Contractor Name FROM TO 1 DESCRIPTION
2 G .300ft 520 fcl
35.36 ft. ft:
NC Well Contractor Certification Number 15.OUTER CASING for multi cased welts OR LINER �f a liable
FROM TO DTAMElER THICIQYESS MATERIAL
I�Q Z'Y1.EJl/3� !.�•/i't� ft ft; in.
Company Name
16.INNER CASING OR TUBING(Leoth 21 dosed-loo i
2.Well Construction Permit#: A D LZ, J 0 7 FROM TO DIAMETER THICENWS MATERIAL J
List all applicable well construction permits(i.e.WC Comity,State Variance,eta) �. tt �07 ft C•7/s in• T T
3.Well Use(check well use): ft
Water Supply Well: 7.SCREEN
FROM I TO DIAMETER SLOTSIZE I THICKNESS MATERIAL
❑Agricultural ❑ 1 cipal/Publie ft ft is
❑Geothermal(Heating/Cooling Supply) esrdential Water Supply(single) ft fa �•
❑Industrial/Commercial Residential'Water Supply(shared) k
8.GROUT
OIrrigation ❑Wells>100,000-GPD FROM TO MATERIAL EMFLACEMWTMEIHOD&P.MOrArr
Non-Water Supply Well: ft 2-3 ftAfC 6L i-
AA i
❑Monitoring ❑Recovery fe ft )
Injection Well: r
• fL ft'
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM zo MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage & ffi
❑Experimental Technology El Subsidence Control ft ft.:
0-Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21.Remarks) FROM I TO I DESCRIPTION color,hardness,soiVrock type,gmin six.eta
fL fL1
4.Date Well(s)Completed:Z 1 0�7r�J. Well ID# fL
-7M
5a.Well Location: C� ft fat 553` d
& ft; owl
Facility/Owner Name FaciglyID#(if applicable) & 'd e,;� tz}
ft
SSAat% INN J,l I t 'Dr. s "ft
Physical Address,`1rty,and Zip _ `�- ft. ft.,! :t 2023
FO�Sj+h �N
County - - Pared Identification No.(PIN) ✓�s'��d%ur,)�"
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Wong is sufficient) 22.Certification: I I
6.Is(are)the well(s): cyeermanent or-- ❑Temporary 26 Sipah.6 gftd tifie Well Conhactor Date
Bysigning thisform,.Thereby certify that the well(j)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ko ISANCAC 02C:0100 0r'I5ANCAC 02C-0200 Well Construction Siandardr and that a copy
Ifthis 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#11 remarks section or on the back of this form.
23.Site diagram or additional well 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 Remarks Box).You may also attach additional pages if necessary.
drilled: Q 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft)
For multiple wells list all depths fdIerent(example-3@200'and 2@100) Submit this GW 1 within 30 days of well completion per the following:
I
10.Static water level below top of casing. O 24a.-For All Wells: Original form to Division of Water Resources (DWR),
&'usi-+" (ft) Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casin
Il.Borehole diameter: In b (in,) 24b.For Infection Wells:;Copy to DWR,Underground Injection Control(IUC) !,
n Program,1636 MSC,Raleigh,NC 27699-1636
12.Well-construction method: i"1 O 1, 24c.For Water Supply i nId Oaen-Loop Geothermal Return Wells Copy to the i
(.e.auger,rotary,cable,direct push,eta) county envuonmentat health departrnent of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d For Water Wells Drodncin¢over 100 000 GPD Co to D
Permit Pro Copy CCPCUA
13a.Yield(gpm) Method of test: � g�>1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type:_ 1'1 I Amount: t v
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Form GW 1 __--