GW1-2023-02624_Well Construction - GW1_20230410

WELL CONSTRUCTION RE,CORD(G%V-1) For Internal Use Only:
1.Well Contractor Information:
t _
Jti'1 del PQ •. "<- 14.WATER ZONES
Well Contractor Name `Y� =s•• '�-...__ FROM 70 DESCRtP'r10\
/l1C�C yo7`l- APR 1 0 2Q23 22ztsR. 2'iG C W fOdi, -� S�ttrd V
NC Well Contmetor Certification Number 15.OUTER CASING(for multi-used wells)OR LINER('d a Garble)
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ii1:Gi:'i.i. t -r:�J ( �,t FROAi. TO DI,,,11EfER THICK\'FSS MATERIAL
�ulKrr /'r! �'j/�J/!"OY�1��7t1�/�.�,5,;;•ti;a �i:; ft. in.
Company Nato t• fL
16.INNER CASING OR TUBING( ciithermal closed-loon}
2.well Construction Permit ft: w7n 0(- 0 12 3 ``-, t:ROal To DLAAIETER F TntCK\ESS alATEmAL
List all applicable well construction permits ri.e.UIC,County.State,[urfance,eta) ft. ft. in.
3.Well Use(check well use)- ft ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAhTETER I SLOT SIZE THICKNESS MATER1
❑Agricultural ❑Mtnlicipal/Public Z O fr. z.2 t. 2 `n t /o q0 PttG
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft• ft. in,
❑IndustriaI/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FR01I TO DLITERIAL EMPLACCt,111\T 1tErHOD S AMOUNT
Non-Water Supply Well: 2-2-3 B- 2 2VOf-
ject$Monion'"I ❑Recovery220 i, 1 A)�f 'TrrmmCL ileq:5 A
Igjection'Vell: /
❑Aquifer-Recharge ❑GrotmdwaterRentediation ft. ft.
19.SAND/GRAVEL PACK(if a ncable
❑Aquifer Stooge and Recovery ❑Salinity Barrier FROM TO MATERIAL a EMPLACFI\IE,N'T IMTHOD
❑Aquifer Test ❑StomnvaterDrainage 29f) IL -223 ft- GIO 1fr `I Tfl t'twit� (o
❑Ex erimenta Technology l Tech rau
p �y ❑Subsidence Control it. n.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessarc)
❑Geothermal(Heating/CooliugReturn)_ ❑Other(explain under/t21 Remarks) FROM To DESCRIPTION War.hardness,nil/roc[ e,2=ln stir,etc.)
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d, ft. �re) It.. U.
S /f Sd'1
4.Date Nell(s)Completed: 3'2^ 2- 'ven my f1 Pl-wk;1 o y C F D,t ft* 'fo r7 ft. 0r- rG S
Sa Well Location:
S! o ft. nr ft. 3/
rt. rt.
6 r
/
Pacility/On•nerName FacilitylD#(ifapplicable) oZr t. ft. 1/ ;�F ce-e Slip
09-4eL;N V C 1 2`6 31 Sr 163�7�rt. t It. "�an 1 o rw /d S•-4
Physi6l Address,City,and Zip / l D ft. // ft'
oo� Ig2%063�1D�/p 21.REMARKS
County Parcel Idemitication No.(PIN) �5/ -_O_�h. _A0 O"
5b.Latitude and longitude in degreesiminutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
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6.Is(are)the well(s):kermanent or ❑Temporary Signature of •nificd\Neu tractor Date
By signing thisforarn,I hem •certi -dial the icell(r)ryas(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or JdNo 15.•f A'C.tC O2C.0100 or l5A A'C fC 02C.0200 well Cattstruction Srandards and iitat a cnPV
If this is a repair,fill out/•rrau-ir a it construction infnrmarion and exploit[the nature of tire o(this record has been prorided to the me11 oumcr.
repair under#21 rcinarla section or on the back ojthis foray.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells(laving 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'Sec Ovee in Remarks Box).You may also attach additional pages if necessary_
drilled:
24.SUBIYi1TTAL INSTRUCTIONS
9.Total well depth below land surface: Z YD (it}
For inul ipfe cells list all depils ifdilfarent(example-3@200'and 2@/00� Submit this GN-1 within 30 days of well completion per the following:
Static water level nnter level is aboveecasing,roe g
10. 24a. For All 'Wells: Original form to Division of Water Resources (DWR),
If it Information Pin Unit,1617 MSC,Raleigh,NC 27699-1617
a "+"below top of casing: ( ) Processing
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11.Borehole diameter:..... n? 7 / (in•) 24b.For Injection'Wells:Copy to D,)VR,Underground Injection Control(lUC)
e Prot,'rarn,1636 MSC,Raleigh,NC 27699-1636
12.well construction method, JO�?/L 24c.For Water Supply and Onen-Loon Geothermal Return Wells-Copy to the
(i.e.auger,rotary,cable,direct pasty,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY"'ELLS ONLY: 24d.For'Water'Vey producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) R4ethod of test: Per
mit Program,16I1 MSC,Raleigh,NC 27699-1611
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13b.Disinfection type: Amount-
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