GW1-2023-01968_Well Construction - GW1_20230227

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
J0 ,� �, 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractory/Name (� ft. V ^ ft• ^ ^�
W —� ft. �l ft. •C v
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells) R LINER if a livable)
` , FROM TO DIAMETER THICKNESS MATERIAL
�Q J-& 1 L• O ft. 15 41 ft. &I in. S -2) p
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: '�7 71 (o?/ ESCREEN
TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i e.UIC,County,State,Kilance,etc.) ft. fa
ft. in.
3.Well Use(check well use):
Water Supply Well:PP y TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural unicipaMblic p ft. ft. in.
Geothermal(Heating/Cooling Supply) WRIsidential Water Supply(single) ft. ft. in.
IndustriaUCommercial Residential Water Supply(shared) 19.GROUT
-Irrigation FROM TO MATERIAL EMPLACEM NT METHOD&AMOUNT
Non-Water Supply Well: ft. 3 Z ft.
Monitoring 13Recovery ft. ft.
Injection Well: ft. ft. �S
Aquifer Recharge QGroundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ❑Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) �'fracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soi mck ty rain size,etc.)
Geothermal Heatin C ling Return) Other(explain under#21 Remarks)
4.Date Well(s)Completed: 1 -3-2-5 Well w ft. ft.
. G
5a.Well Location: t. ft
ro
ft.
Facility/Owner Name / pFacility lD#(if applicable)
�p ,(�U't 7—s'�V�� C!C/t• DK4K A(/— ft. ft.
Physical Address,City,and Zip Z7g it.
b 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.C tion:
3�.379233� N - 781 ?63' 7 .2oS W ( Z�,
6.Is(are)the well(s) rmanent or Temporary Si of Certified Well ontractor Date
R_� By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair loan existing well: OYes or O with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information explain the nature of the copy ojthis record has been provided to the well owner.
repair under#21 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 site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER ofwells construction details. You may also attach additional pages ifnecessary.
drilled: �/-� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: '32Z (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
/J y above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: K D construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2 Method of test: u/h 24c.For Water SnDDty&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: F4 r H Amount: 7 fl(-t h t--*A, completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016