GW1-2023-02446_Well Construction - GW1_20230404

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
r l i J,��va+V�3'� l 1(J�fJ�►l3 `ram' "?-�� 14.WATER ZONES
Well Contractor Name FROM i TO I DESCREMON
5 rt. _ rt. I�Id t,,mot 1 G
N/C�Well Contractor CertifintianNttmber 15.OUTERCASING(for multi�asedwells ORLINER rfa lLc ble
�i+ ���` r {_,�T��� f I.�_` FROM TO DIAMETER 'ffiC[QTFSS MATERIAL
in.
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Company Name
' /r 16.INNER CASING OR TUBING(geothermal closed-too
2.Well Construction Permit#-- (!� L FROM To DIAMETER TTIICIINFSs MATERIAL
List all applicable well construction permits(i.e.UIC,Co ly,State,Variance,eta) /_/ fL
71 fL �11 rn- &t 4& Lvc_
3.Well Use(check well use): 9-z- fL ,-4A 'L 'r 1D e4- ! 1
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THiCEN SS I MATERIAL
❑Agricultural ❑Municipal/Public m it. in.
❑Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) n. It. in.
❑1ndustriallCommercial OX6;ldential Water Supply(shared) I&GROUT
01ni lion ❑Wells>100,000 GPD FROM I TO MATERIAL E ffLACEM E UMEMOD&AMOUNT
Non-Water Supply Well: � It. fL �! .� '
❑Monitoring ❑Recovery ft_ fL Y2/
Injection Well:
n n
❑Aquifer Recharge ❑Groundwater Remediatitm
19.SANDlGRAVEL PACK rf a 'cable
❑Aquifer Storage and Recovery OSalinity Barrier FROM I TO I MATERIAL I E ZILACEMENTMETTtOD
❑Aquifer Test ❑StormwaterDrainage - B. �' ft.
❑Experimental Technology ❑Subsidence Control ft. it.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets ifuecessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#{21 Remarks) FROM TO DESCRIPTION color,hardness,soilfrocktype.gmfn sae,etc
L 1L fL ✓L Gr��.
4.Date Well(.)Completed: - Well ID# /L% ft: /{-t Gt�p jirCL Iy r�
Sa.Well Location: ?7 rt. Lin ' fL .T-1�� p
Facility/Owner Name Facility ID#(if applicable) n' ft_
-� !s
Physical Address,City,and Zip
21.REMARKS -1` _ .7
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County _ Parcel Identification No_01N)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one Wong is sufficient) ` t t 22.C tification,
3S0 dal Zv N r7e-` 31 �Z w
6.Is(are)the we11(s):,l�rmanent or ..❑Temporary Signature of Certified Well Contractor Date
Byslgning thisform,1 hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ftloV 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair•fill out known well construction information and explain the nature of the ofthis record has been provided to the well owner..
repair under 921 remarks section or on the back of thisform.
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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMPITAL INSTRUCTIONS
9.Total well depth below land surface: 1• (ft) Submit this GW-1 within 30 days of weII completion per the following:
For multiple wells list all depths tfdifferent(example-3�200'and 2 a�00T 1
10.Static water level below top of casing: Z (fL) 24a. For All Wells: Original form to Division of Water Resources (DWR),
I10.Static
a above casing,use o Information Processing Unit,1617 MSC,Raleigb,NC 27699-1617
t 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter_ CID-) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ►�1/Ll.L O- l,Ly ''�/ 24c.For Water SuvDlv and Open-Loop Geothermal Return Wells:Copy to the
C_e.auger,rotary,cable;direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100.000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Perm Program,1611 MSC,Raleigh,NC 27699-1611
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s
13b.Disinfection type: Amount:
Form GW-I North Carolina Department ofEnvuonmental Quality-Division of Water Resources Revised 6-6 2018