GW1-2023-02753_Well Construction - GW1_20230417

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WELL CONSTRUCTION RECO (GW-1) For Internal Use Only: • i .
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• 1.Well Contractor.Information:
l .. L• Sy r 1.C/l/1u1 14.WATER ZONES
Well Contractor Name FROM TO DESCRD?11ION
ft. ft
NC Well Conbactor Certification Nttmbe�
'd(Jy,Y7 15.OUTER CASING(for multi-cased wells)OR LINER(if op licable) •
ri,t1T-Ma/ki FROM TO DIAMETER •THICKNESS MATERIAL
f. ft is
Company Name
• 16.DINER CASING OR TUBING(geothermal ciceed-loop)
2.We Construction Permit#: 3 (5 `� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pennits(l .WC,County,State,Variance,eta) f/ ft 15 fL• .,5V' ix'.
711.1 c& p
3.Well Use(check well use): ft ft in. r I
Water Supply Well: • d7-SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
• ❑Agricultural • Municipal/Public - ft ft •- ' M. ,
❑Geothermal(Heating/Cooling Supply) idential Water Supply(single) R ft _ in•.
❑Industrial/Commercial Residential'Water Supply(shared) 18.GROUT •
❑Irrigatiotm 7 ❑WeIIs>100,000 GPD PROM TO MATERIAL EMPLACEMENT METHOD de AMOUNT
Non-Water Supply Well: 0 ft 2-3 ft �r
• ❑Monitoring ❑Recove•
N�'fi 1 r 4•
• Injection Well: •
ft.ry ft. IrkN
A. , 1, t A..7.,ri/
❑Aquifer Recharge ❑GroundwaterRemediation P
❑Aquifer Storage and Recovery • ❑S Barrier 19.SAND/GRAVEL PACK(if applicable) •
FROM TO MATERIAL EMPLACEMENT METHOD -
❑Aquifer Test • ❑StormwaterDrainage • ft fa
❑Experimental Technology ❑Subsidence Control . ft ft •
• ❑'Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Healing/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO • DESCRIPTION(color,horde soil/rack type era;a sae etc)
ft ft
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4.Date Well(s)Completed: 3-3I'Z3 Well ID# • ft. •ft
5a.Well Location: ft. 1� I .. �- She(I e t?
• Factlit�/Owner Name U V FacilitylD#(ifapplicable) ft ft. i'- '} _
3h�,��orvn �d c(u �, viz .��ax :: k. .
Physical Address;City,and Zip • 1 ft ft A FI �l ?0ZJ
O� (�(t t 21.RENtARKS,(, H ^
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County Ui �f • Parcel Identificatioallo.(PIN) 1Fi�C•iF 3h' 11 :J� t+
inrl :^ai •
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3h1 a-7i 11. N 8l ' 0 ' 3i, W
6.Is are the wells: ❑ ! Date 2 3
( ) () Armanent or ❑Temporary Aso �awellContactor Due
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By signing this form,Ihereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I To ISA NC4C 02C:0100 or7X4 NC IC Well Construction Standards and that a copy this is a repair,fill out mown well construction information acid explain the nature of the of is recordhas been provided to the well owner.
If
'repair under#21 remarks section or on the back of thisfonn.
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 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages ifnecessary.
drilled:
7� t 24.SUBMITTAL INSTRUCTIONS ' . '
9.Total well depth below land surface: (ft)
For multiple wells list all depths ifd�erent(example-3@200'and2©I00) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: �p D • (ft) 24a. For All Wells: Original!form to Division of Water Resources (DWR), •
Ifwater level is above casing:use a+" ` Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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11.Borehole diameter. la D •(m) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(TUC)
� Program,1636 MSC,Raleigh,NC 27699-1636
.12.Well construction method: I l A+a-1 Air
(Le auger,rotary,cable,daectpush,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the '
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county environmental health department of the county where installed
• FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producin •
g over 100,000 GPD:.Copy to D
13a.Yield m I f�L •� ' Pelmit Program, MS Raleigh,NC 27699-161l • CCPCUA
(gP ) Method of test C' ? is
13b.Disinfection type: IAl17 Amount / •✓
to a •
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'Fenn GW 1 North Carolina Denartmeat nfFr vimnm...eet A.«t:«._rya__-_-...,,.. .. '