GW1-2023-02528_Well Construction - GW1_20230406

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.IW,elll Contractor Information:A 4LM t M 10 Q✓/)
y 14.WATER ZONES
Well Contractor Name
FROM TO DESCRIPTION
j
ft ff.
NC Well Contractor Certification Number l 15.OUTER CASING for multi-cased wells OR LWER if a licable
f•{es �'.N✓r rU dti���y i G� f FROM TO DIAMETER THIC[NESS MATERIAL
�J t ft. ft. is
Company Name
16.INNER CASING OR TUBING fizeothermal closed-loo
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) D ft' S" ft 2 In. sLh (�U
3.Well Use(check well use): ft. ft � in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOTSIZEJ THICKNESS I 51ATEiFul
❑Agricultural ❑MunicipallPublic ft ft. Z in.
.S
❑Geothermal(I-Ieating/Cooling Supply) []Residential ,S
Residential Water Supply(single) ff. ;a
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
❑hri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft- -?, S [t �f s- L r.s v, y F1c Ld
Or Ionitoring ❑Recovery ft. ft. �f tee- e
Injection Well: &"e V d o"o
❑Aquifer Recharge ❑Groundwater Remediation ft EG
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage �,� ft �L-s ft. / �J Cr z -5 mot*+ Our-
Sa �..
❑Experimental Technology []Subsidence Control ft. IL
❑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,h2rdness,sollfrock In sire etc.
® ff. S ft LP
4.Date Well(s)Completed: _ -Z3 Well IN 1/Y) - / tt. ft.
C t/ ' Sa..s/ d, fa tei�l/
5a.Well Location: ff' ft.
ENC -C- Clue Mr ca
, I St>,l e5 /VC b o 0 3 ZO1*37 ft. ft.
Facility/Owner Name Facility lD#(ifapplicable) ft ft (^-:' : •,•` '� •.,, j
ft fL
9
Physical Address,City,and Zip ft. ff. APR
•�
C, 2023
C reL f ed✓ 21.REMARKS
County Parcel Identification No.(PIN) nt,rt ?•r :t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one fattlong is sufficient) p to VV
IBP 22./Ceertiifreattio�nn:
3S'• 1 Z 9 SO 6j N -7 7 6 2 `'f (1 /
6.Is(are)the well(s): ermanent or ❑Tempor(ary Signature ofCcrtificd Well Contractor Date
By signing this form,I hereby certify than the wel vas(were)constructed in accordance ivith
7.is this a repair to an existing well: ❑Yes or 15A NCAC 02C.0100 or ISA NCAC 02C.0100 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature of die of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
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-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: 14/. ft.
For multiple-wells list all depths ifdtPere»t(example-3@200'and 2@100) ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 3• (ft.) 24a. For All Wells: Original forma to Division of Water Resources (DWR),
Ifwater level is above casing,use"+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: fin,) 24b.For Infection Wells:Copy to MR,Underground Injection Control(RUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: A ug etry 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie.auger,rotary,cable,direct push,etc.) V 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:
Permit Program,1611 MSC,Raleigh,NC 276997611
,
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-2018