GW1-2023-02020_Well Construction - GW1_20230227

WELL CONSTRUCTION RECO GW 1 For Internal Use Only:
I.Well Contmetor•Iaformation: `
9R:S�IS1A� IY
NWATMI ZONESWellCoatcacorNamb TO DESCRrP1iON
(e pftNCWellConhaerorCertifioadcaNumber ft •i
FROM TO
CASING for multi-called wells OR LINER rf a Iinble
FROM TO Dtsnrcrca ZALE IOVESS MATERUL
CompanyName )) L'• .ft ft I I �•
2.Well Construction Permit#:_ l p �J,j �J '��Z FROM C TSOIIVG OR TUBING eotberma!cloyed-loop)
List all applicable wll e Con truatiatt pernats(�e,MC;County,State,Yariance,etc ' ft 2 DERin. ��SS MArEgiAI'
J �
ft ✓` it h)CK t/t.
3.Well Use(check well use): ft ft - in
Water Supply Well: 7.SCREEN
❑Agricultural ❑Municipal/Public -om TO DIAMETER SLOT SIZE THICIOYESg MATERWL
ft ft in
❑Geothermal(Heating/Cooling Supply) Sidential Water Supply(single)
❑1ndustrial/Commercial / ft
❑ResidentialWiter Supply(shared)
❑krri lion 18.GROUT
❑Wells>100 000 GPD FROM To MATERIAL EnrPLncEnrEKrMetsoD trAMOlnvr
Non-Water Supply Well: ft �3 ft ��.
❑Monitoring ❑Recovery 4 ft ft -e
Lajection Well:
❑Aquiferltecharge ❑Groundwater Remediation it ft
❑Aquifer Storage and Recovery ❑M�yBarrier 19.SAND/GRAVELPACIi ifa licable
FROM CpVlENT
❑Aquifer Test ❑ TO MATERIAL EMp1 A 1=010
StormwaterDrainage tt ft �
❑Experimental Technology ❑Subsidence Control ft
❑'Geothermal(Closed Loop) ❑Tracer 20.DRILL IlVG LOG atlaeh additional sheets if necessary)
❑Geothermal(Heating/cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRZPrrox color,bardeess:o�hoek e• is sae ere
ft ft
22_ i.,
4.Date Wells)Completed: 2 3 Well M# ft A
5a.Well Location: ft ft r S
Facility/Owner Name Facility ID#(ifapplicable) ft ft k y..•<• r ,
e to 7 4/l. (R J72 S �1 dYYl1 D l�l is ft ft
Physical Address,City,and Zap „
G Y1 21.RE fMARNS.(, f t ,,�• �•:t
countParcel Idendfieatioallo.(PIN) ' :,•f..r G+Ge OiFi:.ki
5b.Latitude and longitude in degrees/miuntes/seconds or decimal degrees:
(ifwell field,one Wong is sufficient)
IA ' 24 �V A P 3 r 22.Certdie tioa:
W
6.Ls(are)the welI(s): Aermanent or ❑Temporary Sigaahni bfCertifiedwcu Contractor ! Date
war
7.Is this a repair to an existing well- ❑Yes or NO 1 f NCAgC 01C:0100 or 2S,f I C Cr 01C.0100 hat ihe r1Ve11 Consttrruc on Standards d t�a copy
Ijthls is a repair,fill Ord brawn weR eotutru6tion/i formation and)hspplain the nature ojthe Of'th/s record has been provided to r.
the well owne repair unddi#21 remarda section or on the back ofthisform.
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
ed
conch:ction,only 1 GW 1 is needed kidicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary
drill
/ SUBMTiTAL INSTR
9.Total well depth below land surface: '(�CP 6 t 24. UCTIONS
Formultlple wdis list all depths iifdoerent(- p/e-3Qa 200'mtdlpa 100) (f t) Submit this'GW 1 within 30 days of well completion per the following:
10.Static water level below top of casing. D ft 24a.-For All Wells: Original form to Division of Water Resources (DWR) '
lfwaterlevelis above easin&:use/�+ ,> ( ) knformationPrccessingUnit,1617MSg Raleigh,NC27699-1617
11.Borehole diameter. is 3 (m� 24b.For Injection Wells:Copy to byVR,Underground knjection Control(IUC)Program,1636 MSC,Raleigh,NC 27699-1636
12.Welt construction method:
(La-auge,rotary,cable,diceet pull,etc) 24a For Water SnnpIv and Ooen-Loo o Geothermal Return Wells Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: .
24d.For Water Wells roducin of er 100 000 GPD:Copy to DWI;,CCPCUA
13a.Yield(gpm) / Method of test:_ to__-
Form Pit Prograzn,l 11 MSC,Raleigh;NC 27699-161113b.Disinfection type: Amount: 1 OW-1 North Carolina D artmeat o
ep fFnvimnmental0.uality-Division ofwater�.caces
Revised 6-6-2018