GW1-2023-02525_Well Construction - GW1_20230406

WELL CONSTRUCTION RECORD(GW 1) For intemal Use Only:
1.Well Contractor information:
' 's, e�`� 14.WATER ZONES
Well Contractor Name FR06i TO DESCRIPTION
NC Well Contractor Certification Number ft, ft.
,t�. 15.OUTER CASING for multi-cased Ivells OR LINER if a lieable
ei S iL /�t/r�rCr-I"es♦�zt FROM TO DIAMETER THICKNESS MATERIAL
Company Name ft, ft. in.
16.INNER CASING OR TUBING eothermai closed-loop)
2.Well Construction Permit#: FRO51 To DIAMETER THICKNESS nATERIAL
List all applicable well construction permits(i.e.U/C.County.State,Variance,etc.) Q ft. R. in.
_5-�VJ , vC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
DAgricultural FROM TO DIAMETER SLOT SIZE THICKNESs MATERIAL
❑Mturicipal/Public S ft. ! ft, a in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) "U)b soh `�0 Pve
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑hri ation 1S.GROUT
Non-Water S ❑WellS>100,000 GPD FROM TO nATERIAL' - EMPLACEME METHOD R AMOUNT
Ls upply Well: NTtt, R,
I Pellei 5 6-re-if, a1
onitoring ❑Recovery
Injection Well: R, 3 ft D c'tie
13Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK if a lieable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drains e - ft. ft. 0 t-•ww
. a,..�rz
❑Experimental Technology ❑Subsidence Control ft, r
R.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additioaal sheets if mecessa
OGeothermal(Heating/Cmoling Return) OOther(explain under#21 Remarks) FROM To DESCRIPTION rnlor,hardoe solViock r, rain size,etc.)
7 c� p fr. jam- fc.
4.Date Well(s)Completed: J '6 '1-3 WeII ID# ft. ft,
A t9�-NGL QCt�r 1•d w
SGGa.Well Location: / R, fL
LN'-CCE C�Mi`LA[ �QIPs /Y'cbae� z�1�.37 ft. R,
Facility/Owner Name
Facility IDO(if applicable) ft. .;-.... �p
Z 0' 6 St,-e e f i"/(� ft. ft. • '� m-4..' vM s ' tk."�"
/l se 6,v 2� l 9 ft.
Physical Address,City,and Zip ft, ft. t
2 LULJ
d o f �� 21.REMARKS
County
Parcel Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lablong is sufficient) 22.Certification:
35. 129,5'06 N _ 77. GZY816 w
6.is(are)the�vell(s): CTPermanent or ❑Temporary Signature ofCcrtifrcd Well Contractor Date
�_� By signing thisform,Iliereby cei-if}that the me//(s);vas(were)consawcted in accordance nvth
7.Is this a repair to an existing well: ❑Yes or L51Y0 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a Copp
lfthis is a repair,fill out known well consnztctimi in/at'mation and explain the natrn a of dle of this record has been provided to the urll onmer
repair under#11 remarks section or on the back of this•form.
23.Site diagram or additional well details:
S.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.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: at.) '
For nuthiple wells list all depths i1•dierenr(erantple-3Q200'and 1C1o03 Submit this GW 1 within 30 days of well completion per the following:
10.Static water level below top of casing: 3-6 (ft) 24a. For All Wells: Ori&inal form to Division of Water Resources (DWR),
if Ivater level is above casing,use"+•• information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
(i.e.auger,rotary,cable,direct push,etc.).Well construction method: I..,mil' e�" 24c,For Water Supply and Open-Loop Geothermal Return Wells:Co to the
county environmental health department of t e county where installed Copy
FOR WATER SUPPLY WELLS ONLY: . '
24d.For Water Wells producing'over 100 000 GPD•Copy to DWR,CCPCIJA
13a.Yield m Permit Program,1611 MSC,Raleigh,NC 27699-1611
�P ) Method of test: -
13b.Disinfection type: Amount: -
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018