GW1-2023-02120_Well Construction - GW1_20230303

WZJ,L UVINSIRUC;110N RECORD (GW it For Internal Use Onl
1.Well Contractor Information:
t7 L p
/�(,I� f 14.WATER ZONES
Well Contractor Name bf FROM TO DESCRIPTION
L10;�3 2� ft. W ft. 2 rc IdG
Z60 ft Ir 13G /n n rwl,�C C�v�rfz
NC Well Contractor Certification Number
T
)) 15.ODTERCASiNG rot ort!Ll',— dwells OR Nl R r.f a ueable
Ov L ($ Weh Or�/1•dq IROM TO DIAl11ETER THICKNESS MATERIAL
f 1 I Q 11 6 in. -2 I f VG
Company Name
16.INNERCASINGOR ING(eathermaldosed-too
2.Well Construction Permit#. 1 FROM TO DIADIEETER THICKNESS MATERIAL
List all applicable trell c0ns6vc1i0n permits(i.e-UIG Cotmty State,Variance,etc.) ft ft. fn.
3.'Nt fl Use(chestrwell use): ft. ft in
Water Supply Well: 17.SCREEN-
l;n Ci al/Pub11C RROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
A cultural p it. Ft I Tn
Geothermal(Heating/Cooling Supply) csidcatial-Water Supply(single) it. ft I I In.
IndustriaUCornmercial Residential Water Supply(shared) 19.GROUT i
Irrigation FROM TO MATERE4L EMPLACEMENT METHOD&AWOUNT
Non--Water Supply Well: Q it Z Q ft. 1
lia Poor
Monitoring QlRecovery ft it.
Injection Well:
ft Aquifer Recharge 00roundwaterRemediation ft.
19.SAND/GRAVEL PACK,(if a licable
Aquifer Storage and Recovery OSalinity Barrier FROM TO I MATERIAL IEMPLACEMENT NI FTHOD
Aquifer Test OStormwater Drainage ft. ft.
I
:]Experimental Technology OSubsidence Control ft. ft
- Geothermal(Closed Loop) Omacer 20.DRII.LWGLOG(attach additional sheets if necessarv)
Geothermal(Heating/Cooling Return) i Other(explain under#21 Remarks) [ROM TO DESCRIPTION(color,hardness,soilfrock e,grain sire,etc.)
O it '72 ft. PG�
4.Date Well(s)Completed: -t 2` Z Weil IQ# 7`L It• 300
Wey QFqndr-
5a.Well Location: ft ft.
ann dfQ1 It. ft.
Facifity/Owncr amc /+ Facility ID#(if applicable) ft. ft.
j Z3I �(�$� •/ U eG ft. ft.
Mysical Address,City,and Zip ft. it. I MAR 0 � Z023
21.RFTlfARKC I -
County Parcel Identification No.(PIN) I ;C i� ...•.. .' :.. ... .':� l::
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wcU field,one lattlong is sufficient) 22.Certificatio
3G- 578q* N - 31 56 i Y5-F20 W
6.Is(are)the wells)I- ermanent or OTemporary Signal=ofCcrtified Well Q.9 tractor Date
� B},signing this form,I hereby)certify that the ttell(s)was(were)constructed in accordance
i 7.Is this a repair to an existing well: Yes or f=7"Q svidt 15ANCAC 01C.0100 or ISt(NCAC 02C.0100 Well Construction Standards and that a
1f this is a reaair,fill out/crown well construction information and explain the nature of the copy of this retard has been provided to the ivell owner.
repair under#21 remarks section or on due back of this form
23.Site diagram or additional well details:
3.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 of wells construction details."You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 300 00 24a.For All Wells: J� g:
mit this foun within 30 days of completion of well
For multiple wells list all depths if dperent(arample-3 200'and 2&100) construction to the follo
I ,.t
10.Static water level below top of casing: 2v (ft-) Division of Wat Ir Resources,Information Processing Unit,
1fnater level is above casing,use--'-" 1
1617 Mail S twice Center,Raleigh,NC 27699-1617
11.Borehole diameter: G Its, (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
I1' 12.Well construction method:'__11 r Rode+, above;also submit one coy of this form within 30 days of completion of well
I
Le.auger,rota construction to the foltowm
(- ge rotary,cable,direct push,etc.}
Division of Water Resources Underground In ram,
FOR WATER SUPPLY WELLS ONLY: l ' Injection Control Program.
d 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yleld(gpm) o Method of test: ter tf r-t 24c.For Water Sunn1v J 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: Amount: 10 U Z, completion of well construction to the county health department of the county
where constructed.
FormGW-1
I NorthCarouaDepartmentofEaviroamentalQuaiity-DivisionofWater� ources Revised -2-_016