GW1-2023-02392_Well Construction - GW1_20230404

WELL CONSTRUCTION RECO _ GW-1 ForinternalUse Only:
' I.Well Con ctor.Info tioa•
r 14.WATEA Z, I
Well.CoatactorName" FROM TO DESCRIPTION
• 3 5�3 s •. �o� �' avo n � � •
C Well Contactor CertitieationN ft tt
15.OTMR CASINGm -cased wo R LINERCIrap liable
_ FROM TO DIAMETER THIC[QYESS MATERIAL
Company Name ft
#: /7 l�5 (/� 16'INNER CASING ORTUBIIVG
2.Well Construction Permit eothermai dosed-too
FROM TO DIAMETER TSIClOVESS
Litt aU applicable well eonrtrudion permits MATERILAL(t a UlC Corny,Srat 1 Variance,ue J ft G3 fG Jt' m
K+
3.Well Use(check well use): ft ft
Water Supply Well: 7.SCREEN
❑Agricultural ❑MunicipaUPublic FROM TO DIAMETEg I SLOTSIZE I TEC(aOESS MATERIAL
❑Geothermal(Heating/Cooling Supply) Sidential Water Supply(single) ft ft -
An.
❑1ndttstrial/Commercial I`` f ft m
❑Resideatial'Water Supply(shared)
❑Ixd lion I&GROUT
❑Wells>100,000 GPD FROM TO MAXMtUL EMPLACENTEM MFTgOD&AMOUNr
Non-Water Supply Well: ft 23 ft � J
❑Monitoring ❑Recovery ft ' C
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation ft -
❑Aquifer Storage and Recovery ❑S 19.SAND/GRAVELPACK rfa liable
allnitYBarrier FROM TO MATERIAL
❑A uifer Test EMPLACEMENT METHOD
q ❑StormwaterDrainage ft ft
❑Experimental Technology ❑Subsidence Control ft
❑'Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/CooliagRetum) ❑Other(explain under#21 Rematirs) FROM To DEsezt>YaoN cotor,hardaess soiVmek a sire err
ft ft
4.Date Wells)Completed: 3—/ 7—7-3 well ID# ft ft.
5a.Well Location: ft ft
ft ft - ' ✓:y.r-a �tr' =.a 4_ tl
Facility/Owner Name Faer7ityID#(ifappli ft eable) ft
AAc C' .. ft APR A
Physical Address,City,and zap ft.
ft Ji7a
L�Pp h yam_— J- PC of e• 21.REMARKS.t ?
county ,( �— 1 Parcel I.- eatianNo.(PII;
5b.Latitude and longit�ed in degrees/minutes/seconds or decimal degrees:
(ifwell field,onee lat/loag is sufcieat) {
r ' t QU �Cf ' 7 ' 22.certification:.
N n: 3 —Z Y' Z3
6..Is(are)the well(s):Aermanent or ❑Temporary Sites: e'Nell Contactor Date
Bystgningthisform,Therebyeertifythot thewk(s)war(were)eonsuuctedin accordance with
7.IS this a repair to an existing well:• ❑Yes or /)['1No ISANCAC 02C:0100 or ISANCAC 02C.0200 Wei!t:vnsrruetion Sroctedin and that ewith
Ifthis is a repair,fill out brown well construction information an loin the Harare of the of�his record has been provided to the well owner. copy
'repair.under#21 rema?krsection or on the backofthisform
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 conshvctioa info
construction,only 1 GW 1 is needed Indicate TOTAL NUMBER of wells (add'See Ovet in Rr marks Box).you may also attach additional pages if necessary
drilled:
24.SUBMITTAL INSTRIICTIONS
9.Total well depth below land surface:
Formuiriple we7lrGstall depths lfd�erent(example-3(a),200'and2p100) Submit this GW l.within 30 days of well completion per the following.
10.Static water level below top of casing: (�) 24a• For All Wells: Original form to Division of Water Resources (DWR),
ljwater level is above Garin&.vse"+' Iu&o• ation Processing Unit,1617 MSC,Raleigh,NC.27699-1617
11.Borehole diameter. ,d •(m.) 24b.For Injection Wells:,Co to D
PY WR,Underground Injection control(TUC)
1 n Program,1636 MSC,Raleigh,NC 27699-1636
12.Welt construction method: !Icy Yl.r—/•T/y�'
(-c.ause,rotary,cable,direct push.etc} 24c.For Water Sn I and Ouen-T oou Geothermal Return Wells:Copy to the
county environmental health depaztnent of the county where installed
• FOR WATER SUPPLY WELLS ONLY: .
24d.For Water Wells aroducin m over 100 000 GPD•Copy to DWR,CCPCUA
13a.Yield(gpm) 20 Method of test: Ct'.�.+� Permit Prognim,1611 MSC,Raleigh,NC 27699-1611
y y5
13b.Disinfection type: "I Amount: �y
Form GW 1 North Carolina D epartment ofEavimnmental Quality-Division of WaterResources
'. Revised 6.6_9m A