GW1-2023-02390_Well Construction - GW1_20230404

WELL CONSTRUCTION RLCO (GW-1) For]internal Use Only: .
' 1.Well Co mation:
ffL 14.WATER ZONES
WellContractorName FROM TO DESCRIPTION
3.5 3 s
�0 C) ft ft
ft ft
NC Well Contractor Certification Number
L ^ , 15.OUTER CASING for multi-rased wells OR LINER rf a stable
t/rJi�w_ FROM TO I DLIMETER I THICKNESS I MATERML
Company Name
ft ft I in
n 16:INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: LU.SM.- e5 [(p G Q J FROM j a TO DLIMETER THICKNESS MATERL,I
List all applicable well construction permits(t.e UIC,County,State,Variance,eta.) / ft qg ft• 5 7 in. 7 G 1
3.Well Use(check well use): ft fc hL
Water Supply Well: 7.SCREEN
F
ROM TO DLIMETER SLOTSIZE THICKNESS MATERLAL
❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft in'
❑Industrial/Commercial ❑Residential'Water Supply(shared)
1S.GROUT
❑Irri tion ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft -= ?
p- .Z —� tvu- - =r.
❑Monitoring ORecovery t�
Injection Well: ft ��1 r t
❑A uiferRechar a ft ft
4 g ❑GroundwaterRemediation
❑Aquifer Storage and Recovery ❑Salim Barrier 19.SAND/GRAVEL PACK if a lice le
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage ft ft
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) I FROM TO DESCRIPTION color,hardness,soiUroek a in srse clot
ft fp
4.Date Well(s)Completed: 23 Well ID# ft ft
5a.Well Location: ft ft
sJ o h o All t rr i t l- ftfL
Facility/Owner Name Facility ID#(ifapplicable) ft ft
ft l
t,•
Physical Address,City,and 2Yp ft fA _.� �,•-
L�l�t c� r 21.REMARKS f' vM
Co ty Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwall field,one lat/long is sufficient) 22.Certify ti6n:
3� t 5 r ZL ' N FD ' c ' 3 / W
.6.Is(are)the well(s): permanent or. ❑Temporary 97014 Siguamri:bfCertifieil'•Well Contractor Date /�`—Z3
By signing thisform,I hereby certify that the well(r)r.•as(were)constructed in.accordance with
7.Is this a repair to as existing well: ❑Yes or L5No 15ANC,4C 02C:0160 or'lSA NCAC 02C-0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out!mown well construction information and explain the nature of the of flits 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 construction info
construction,only 1 GW I is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
:
9.Total Well depth below land surface i�( (ft)
For multiple wells list all depths ifdierent(example-3 02 00'and 2CallMy) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: L0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DV✓R),
Ifwater level is above cming,;use ff"+" Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: l�I •(in,) 24b.For Iniection Wells:Copy to DWR,Underground Injection Control(TUC)
1 n -_ Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:_�DgZ}'U /'[�►'
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and OOen-Loop Geothermal Return Wells.Copy to the
county environmental health department 01 the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells Urodncia¢over 100,000 GPD•Copy to DWR,CCPCUA.
13a.Yield(gpm) �� Method of test: Pemmt Program,1611 MSC,Raleigh,'NC 27699-1611
1 t5
13b.Disinfection type: r �'l Amount:
Form GW-1 North Carolina Department ofFnvironmental Quality-Division of WaterResources
Revised 6-6-20 r R