GW1-2023-02526_Well Construction - GW1_20230406

. I
WELL CONSTRUCTION RECORD(GW 11 For Internal Use Only:
1.Well Contractor Information:
I
l4.WATER ZONES
Well Contractor Name FROM TO DESC'RIPTiOn'
30 70 /� .�7 ft. /S B. 1, r T/ct v-
NC Well Contractor Certification Number ft. ft.
15.OUTER CASING for multi-cased welts OR LINER if a Itcable
�^'e5 �/tiCJ t`1-0 n.yt^t C fit.C !1�• r FROM TO DIAMETER TBIC[CNFSS MATEk1AL
Company Name ft• ft•
16.INNER CASING OR TUBING eothet all closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable',ell construction permits(i.e.U1C County,Stale,Variance,etc.) ft. [' ft in.
-� Z .Se 1,' 0 )6 V.C
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
❑Agricultural EOM TO DIAMETER SLOT S12E THICKNESS MATERIAL
5
OMturicipaUPublic ft. J ft in, d�0 y-
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) v1. V e
ft.❑IndustriaUttn Conereial ❑Residential Water Supply(shared) ft. in
❑ltri ation 18.GROUT
❑Wells>100,000 GPD FROM TO ' MATERIAL"' EMPLACEMENT AfETHOD&AMOUNT
Non-Water Supply Well: 3 ft. R. .8e .)4e Pf?l e �ra✓i f /Ow
rEDAquiferStorage
oring ❑Recovery tt, ft e•a�Gr� lJ-r
n Well: z�
er Recharge OGrougdwater Remediation It. R"
and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACK ifa U bleFROM TO MATERIAL 'J.;• EIIIPLACEMEN"IMETBOD
qer Test OStormwater Drajna e _ L ft. ft. ^OL uccr t
- :B� - /J r SO�vr le7Cv- O.urr Ll.w
❑Experimental Technologya
❑Subsidence Control ft. it
OGeothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
[]Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) EOM TO DESCRIPTION(rnlor,hardnM solUiock type,min size,etc.)
it. t S' ft -t A ff
p ems.. . FA•JVdCd!` a-NtC Nr'G!t
4.Date Well(s)Completed d 1 ^L 2 Well ID#, /J 4)--3 it. ft j
CG4 N ark Q a iv
Sa.Well Location: fr. R,
��✓-CC-C- t`he►Y„� S�iPS IVC6 0032-01-07 ft. It.
Facility/Owner Name Facility ID#(if applicable) ft. ft <.4 ..+g,v y`+r Y y,,,•^v"�<
SAeef, 13c,i�r�P7`v.v Z�5>y ft. ft APR JG 2023
Physical Address,City,and Zip it. ft
-OO! 0 Q y F21. MARKS
County
Parcel Iden[ificmion No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sumcient) 22.Certification:
3s « � �06 N �_��. �Zy Gam,,
- W
6.is(ore)the well(s): NPermanent or ❑Temporary Signature orcermiicd Well Contractor Date
__-/ By signing this form,1 hereby-'1665}•that tile',wills)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or L7Pt6 15A NCAC 02C.0100 or 15A NCAC 02C.0100 lVell Construction Standards and that a cop),
If this is a repair•fill aril known well construction igfotniation and arplain the nature ofthe oftins record has been provided to the well owner
repair imder 021 remarks section or on the back of tlits.forni.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Welts having the same You may use the back of this page to provide additional well construction info
construction,only I GW-I 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:
For undliple wells list all depths ifdiperent(example-3@200 and 2Qa 1001 (ft.) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: (ft) "24s. For All Wells: Oripitral form to Division of Water Resources (DWR),
/f water level is above casing,use"+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
(i.e.anger,rotary,cable,direct pussy etc.).Well construction method:_ V f-' 24e•For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY; 24d.For Water Wells producing over 120,000 GPD•Copy to DWR,CCPCUA
13a.Yield m Pemrtt Program,I b I I MSC,Raleigh,NC 27699-1611
(gP ) Method of test: -
13b.Disinfection type: Amount:
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018