GW1-2023-02527_Well Construction - GW1_20230406

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.eWell Contractor C Information:
J /'91 1`� 14.WATER ZONES
Well Contract i 1 or Name FROM TO DESCRIPTION r
-3& 7Z 3,o/ IL f S 7a ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a licable
FROM To DIAMETER THICKNESS MATERIAL
ft. ft. ia.
Company Name
16.INNER CASING OR TUBING =eothermat closed-too
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERAAL
List all applicable ivell construction permits(i.e.UIC.County.State,Variance,etc.) D ft. It. q in. SG/ 0 /4 KC,
3.Well Use(check well use): ft. ft. !.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
[]Agricultural ❑Municipal/Public 5;15 I't• /6- S ft. in, �V�O SL� u v�
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commeicial ❑Residential Water Supply(shared) IS,GROUT
❑hri ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 1 R. l�@n�r+.v �2(��//tfr /c���✓;��' �=/cw
�nitoring ❑Recovery ft. 3 fL o lre t
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Reniediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. /',!; ft. _ -ut-'v -5 0- pi.r' "
-! er f
❑Experimental Technology ❑Subsidence Control tt. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO - DESCRIPTION color,hardness soll/rock type,grain
1size,etc.
r, a 1 ^� 0 ft. 5 S It. Q`` T ct.N Dom-
4.Date Well(s)Completed: J a Well ID# /'�y7 A/r tl ft. ft. bawk 18 ri, .V
5a.Well Location:
EAl-- C'OECAe,,,id11--r6 l,es AlcbOo:3201837 ft. ft.
Facility/Owner Name Facility ID#(if applicable) �-;' �T•� -
//2-0 L) :V--eel, 81-;d%etoN -
a
Physical Address,City,and Zip
ft. ft. APR V r 2023
C re'-y Z -00 D O'1'/t 21.REMARKS -
County Parcel Identification No.(PiN) vl:'el t�ia
5b.Latitude and longitude in degrees/Inintites/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
s. i Z9 �0 6 N 7 7 0 2,9 e i G W � �--a,1/��,.,.�
6.is(are)the wells: *I rmanent or ❑Tem Signature ofCcrtificd Well Contractor Date
porar '3
By signing this form,l hereby certify that the ivell ft)Was(were)constructed it!accotdance ivlih
7.Is this a repair to an existing well: ❑Yes or MKO 1 SA NCAC 02C.0100 a•I SA NCAC 02C.0100 Well,Construction Standards and that a cope'
if this is a repair,fill out known Well construction fluor matimi and explain the nature of the o/7his record has been provided to the ivell owner.
repair under#21 remarks section or on the back of this farm.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having die same You may use the back of this page to provide additional well construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: r 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �-J (ft.)
For midtiple wells list all depths i/'dilferent(example-3@200'and 2(a1tV Submit this GW-1 within 30 days of well completion per the following:
- 24a. For All Wells: Original form to Division of Water Resources (DWR).
/f water•level is above casing,use
f Static water level below top of casing: (ft.) 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
12.Well construction method: `fJ a i^ 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 SUPPLY WELLS ONLY: 24d,For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCIJA
13a.Yield(gpm) Method of test: Permit Program, 1611 MSC,Raleigh,NC 27699-1 61 1
13b.Disinfection type: Amount:
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Resised 6.6-2018