GW1-2023-02519_Well Construction - GW1_20230406

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
��e L 14.WATER ZONES
Well Contm torName FROM TO DESCRIPTION
St. fL
`JS ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if applicable)
1 C t FROM TO DIA3,1E R THICKNESS MATFRIAL
M4 vac
Company Name U ty 1 J a
7, �{ 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#- ✓� g �?) b FROM TO DIA31ETER THICKNESS MATERIAL
List all applicable well constnction permits(i.e.U1C,County.State,ilariance.etc.) ft. ft. in.
3.Well Use(check well use): fL ft in.
Water Supply Well: 17.SCREEN PA Pr
FROM TO DL"IETER SLOT SIZE THICI.'NESS MATERIAL
❑Agricultural ❑Municipal/Public fL It. in.
❑Geothermal(Heating/Cooling Supply) 'Residential Water Supply(single) R. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑irrigation ❑Wells>100,000 GPD FROM I TO 3LITERIAL EMPI ACE3IENNT INIETHOD&AMOUNT
Non-Water Supply Well: �'1 I,- n-
❑Monitoring ❑Recovery fL ft. wo" e
Injection Well: R. ft-
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FR031 To MATERULL E\iPLACEMENT31ETI10D
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control fL ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary
FROM TO DESCRIPTION(color,hardness,soiltrock e,grain s'ue,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft.
R.
Y so l
4.Date Well(s)Completed: f731,,�' well ID# 3 7 `�?�8 �(j I- —7D n- Lj©S �� I
�71, Il t
5a.Well Location: (�-_ft' ( NO R• ( ,.C£1^gt ^p' dL .
t;sbq� ` 6e 1-. .- - . In� ft. oft- Di�v(o✓� CJL.
Fpcility/OwnerNamee c Facility iDtf(ifap�pllicable) � ��.�}--.it' - s R' y
ft.
Physical Address;City;and Zip ft. ft,
21.REMARKS AIR J
County O. Parcel ldentification No.(PIN) -_-
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22 lcati
W a
6.Is(are)the well(s): ermanent or ❑Temporary Signature ofCcaifi/l Vell Contracto ate
PT
Brsigning this form.L hereby certify that the well(s)was(were)constructed in accordance pith
7.Is this a repair to an existing well: ' ❑Yes or _*0 15A A+CAC 02C.0100 or 15A ATCAC 02C.0200 Hell Construction Standards and that a copy
If this is a repair.fill out known well construction information and explain the nature of the afthis record has been provided to the we11 0117ter.
repair under#21 remarks section or on the back of this fann.
23.Site diagram or additional well details:
8.Yor 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 Ovee in Remarks Box).You may also attach additional pages if necessary.
dnited: I 24.SUBMiTTAL INSTRUCTIONS
9.Total well depth below land surface: A 0 5— (ft.)
For multiple wells list all depths if di fferenr(example-3@200'and 2@H00') Submit this GW-1 within 30 days of well completion per the following:
�O 24a. For All Wells: Original form to Division of Water Resources (DWR),
if n!ater level is above casing,use
10.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC.27699-1617
"+" (fL)
11.Borehole diameter- (in.) 24b.For Injection Wells:Copy to DWR,Underground injection Control OUC)
- . - - - nn- LJ (n� Program,.1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: yi i R Q(L 9�� 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLLY WELLS ONLY: 24d..For Water Wells producing over-100,009 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 11� Method of test L Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection typed"1. N Amount:
Farm GW-1 North Carolina Department of Enviromnental Quality-Division of Water Resources Revised 6-6-2018