GW1-2023-02725_Well Construction - GW1_20230411

L� L ONSTRUMMOIN RECORD(GW Il For Intemal Use Only:
I.wen Contractor information:
'rz d A r4,\VATER ZONES
O. TO DESCRIPTIO
woDCannaewrName ft.NCWellContmowr�CertificedonNomber .OUTER CASING far multi-cased weL � V, O:H•`� TO � DIADIEYER '�C�� PVC
r / r ti 1�.
Company Name 16.INNEWCASING OR TUBING eotbermnl elesed-lao
6 pp_O,y MDiANEUML TffitaavFss tvlAraluAL
2.Well Constrnedon Permit#: s — & ft. la
List aU applieabre tvei!constrnetion permlts(La UIG Counq•,scare,Variance,eta)
3.Well Use(cbeek weU MO: 17.SCREEN
WaterSnpplyWeU: FROM To nuMErER sLorslz� .'e�CravEss MATBtirAL
❑Agricultural ❑MtmicipallPublic �n tG tm Q
[Geothermal(Heating/COoling Supply) WN"'endal Water Supply(single) it, ft. u►•
131ndushbl/Commercial ❑Residential Water Supply(shared) M GROUT .
ft. ATA7EtIAt a
O$ 'on ❑WcUs>100,000OPD FROM To —T-20—V'
o &a
NonFiter Supply Well. fl -
OMolvtoring' ; - - — ❑Recovery rL
ft. IL
,RAqui6r,Rpjharp ❑Gronadwater Remediation 19.5 ITLE&Mffr-131 ticable
i.•. 7!lAI1 nL1I. EMLACBEZFr14iEtr1OD
-t7Aquif:r:Stor$pieandRecovery L73alinityBarrier FROM To
❑Aquifer Test { ❑StOrmwaterDtainage IL (/
❑Experimentaleelaaolagy ❑Subsidence Control n'
❑GwthervW(gdsed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets lroecess
FROM I TO DB3CRIP7I0N eelor batdn sQUIMM a etc.
OGeothetmal(FIeatin Cooling Rearm DOther explain under#21 Rematks / ft. y!.� ft. Ay
4.Date W! (s)'jpomplet Well ID# L rL
.__...__
..
Sa.Weil LoeatlontfL ft.
,
rZ
Facility/OwnerN a FacWttyMH(ifapplicable) -
1'�3 S Chglcs l� Cq6nV PI. I cno!0 n.c,'
-
Physical Addmss,Pity,and Zip f - -- '-
7 8 21.REMARIKS Pre
Percerlde" .! •�`'�� atiSCationNo.(PII� ,.••_..... -.✓"=i-�i3'iL'i= � �r.;
F. 5.6:L•;atitude and-long[tada in degrees/minutes/seconds or decimal degreea:
(ifwl1.5e1d,one iitiloag is su®eit ac) 22.Ce radon:
� Signature oft ertiped WellConhsctor Date
:6.1s(arel.the weU(s): �ertnanent or OTemporary '
��+ Bysigning this form,Ilrereby etrrljv that iheweR(s)was(were)constraeted ht aceordaace widt
7.Is,this a repitr to an er3sting.weD: [Yes or * !Sd NCAC 02C.0100 or 15A NCAC 01C.0209 Weil Construction Standards and that a copy
Ijthls it a repairP
1roa
t mown well obnsqucNon lgfarmation and erpldin the nature oft a of thik recordhas beenprovided to the weft owner
7i1-$ei•#2Iarks s�Non or on•the backof this jornt. 23.Site diagram or additional well details:
You may use die batik of this page to provide additional well construction info
ifnecessary.
Box).You may also
same (add S
&For Geopro$e/APT or-Closed-.>4.00p Geothermal wells having the ' e a Over'in Rematlts attach additional pages
cpnstii oon,'onlyl`GVf►l is.needed, indicateTOTALNUMBBRofweUs
drilled ' 24.SUBMITTAL IMMUCTLONS
9.T tal well dMth'%elow land surface; M) Submit this GW-1 within 30 days of wen completion per the following:
Fars ulhyle woUi:llst`al!depths ifdi/ferent(arample-9Qz00'and 2(pn
24s. For All Wells: Original form'to Division of Water Resources (DWR),
i0•Static watglrlovetbelow top of easing:„ •� —(ft.) lnformation processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ijrtriter►evel is move cosL+& �"
r ..- 24b.For Injection Wells:Copy to DWR,Underground Injection Centro!(IIJC)
11.Borehdle diameter: (1n•) Program,1636 MSC,Raleigh,NC 27699-1636
12.Weli•constr'action method:_ M 1�l Q`� C 24c.For Water Sa 1 and O en-I:oo Geotbetmal.Ret aru Wells:Copy to lice
{�e.auger,rotary III cable,disaet push,cw.) talled
county en nntental epartme nt o the county where ins
FORMA I:I SUPPLY WWELLS ONLY- 24d.For Water Wells roduchi over 100 000 GPD:Copy.to;DWR,CCPCUA
" y� t` Permit wgram. 1 SG Egli, C 27699-1 I1
'13a Yield(gpm) I Method of test;
3 02
13b.pisinfec#on type: t Amount. .
Form GWd North Camlina Depmttment of Envimnmeotal Quality-Division of Water Resources Revised 64-2018