GW1-2023-02755_Well Construction - GW1_20230417

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WELL CONSTRUCTION RECO ,(GW-1) For Internal Use Only: • .
' 1.Well Con anformation: •
oeL '14.WATER ZONES . -
Well Coahaeto Na FROM TO DESCRIPTION.
• •9- 5g7 A ao° y-� ft •
ft ft 1
• Well Contractor Certification N 15.OUTER CASING(for multi-cased wells)OR LINER gap liable)
1 s i.. Itni, n + + FROM TO DIAMETER THICEQNESS MATERIAL
Company Name Y 1Wi�/ R ft �-
/����V'�_""'1 16.INNER CASING OR TUBING(geothermal dosed-loop) '
2.Well Construction Permit#: ( J PROM TO DIAMETER THICKNESS MATBRW.
List all applicable well conrtrudlon permits UIC,:Comrry,Slat Variance,de) --e I ft 1 L 3 "' ,5/x- m I,
' pt., -0(.%
3.Well Ike(check well use): ft ft in.
W ter Supply Well: dP •
ROr CRE1To DIAMETER SLOT SIZE THICKNESS MATERIAL
• Agricultural '❑Municipa]/Public • ft ft •_ in.
❑ eothermal(Heating/Cooling Supply) ['Residential Water Supply(single) R ft in.•
❑Industrial/Commercial ❑Residential'Water Supply(shared) 1a.GROUT •
❑7rrigatiop ❑Wells>100,000 GPD FROM TO MATERIAL - EMPLACEME •MEIHOD&AMOUNT
Non-Water Supply Well: - M-0 ft Z3-ft /V e /N,-7 4 ti
• ❑Monitoring ft.
❑Recovery ft
• Injection Well: ft.
por DLLI--•ri.v(
❑Aquifer Recharge ❑GroundwaterRemediation (_
❑Aquifer Storage and Recovery • ❑ga]jnrt yB�ico • 19.S4ND/GRAVEL PACK Of applicable) •PROM TO MATERIAL EMPIACEMENTMETHOD -
OAquiferTest ❑StormwaterDrainage ' ft ft
❑Experimental Technology ❑Subsidence Control ' ft ft
• ❑'Geothemaal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ' ❑Other(explain under#21 Remarks) PROM TO • DESCRIPTION(color,hsrdnea soil/rock tree teals sae.etc)
ft ft
4.Date Wells)Completed: I---G-2-3 Well ID# • ft It. (i�R � 1. p 11
5a.Well Location: 11 ft
ft U ^J"�
�() •r/1 A J o�/'� •
ft ft i #7 " 7 .
• Fa 'ty/OwaerNamo �� Facility DV(if applicable)
ft. ft.
( � / C
a, �- a air.,,i..„,s • v.. ei- .--ft tt I:- T-
Physical A City,and Zip ft ft. ._, z- .•..a Sr' ..
Corm i� ,21.REMARKS Ar APR 1 r7 2023 -
ty Parcel IdentificationNo.(PIN) •
5b.Latitude and longitude in degrees/minntes/seconds or decimal degrees: it `'",',_. i'1 •' '"�3 Una
t(ifwell field,one lit/long is sufficient)) vs
22.Certifi
' 32• 9 • N d/ " Z1 IS " W
� � (-1'7-Z3
6.Is(are)the well(s): L9Permanent or ❑Temporary 'l'7� Signature fC " :Contractor' '. Date
O / •
By signing thisionn,Ihereby certify that the wel(r was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or !M ISANCAC 02C:0100 or754 NCAC 02C.0200 Well Construction Standards and that a copy
"this isarepair,fill out brawn well construction information anderpfain the nature of the of this record has been provided to the well owner. •
'repair under#21 remarks section or on the backofthlsform.
• 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 if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9•Total well depth below land surface: 1A (ft)
For multiple wells list all depths if dierent(rxnapk-3 0'and 2 ap100� Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 6 O • (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),•
Ifwater level is above casing:use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 •
11.Borehole diameter: ! Cm) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Welt construction method: Rey)a .
(r a auger,rotary,cable,duck push,etc.) r '"` -
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
•
county environmental health department of the county where installed
• FOR WATER SUPPLY WELLS ONLY: • 24d.For Water Wells producing over 100,000 GPD:Copyto D
132.Yield(gpm) //;; � Permit Program, MS Raleigh,NC 27699-1611 'CCPCUA
t Method of test (/L�Cit,� gh, ti
I _ •
t
13b.Disinfection type: 'i. ` )'I Amount J 0 h•- .
'Form GW-1 Nn.rh(',nIrn n: ..a . ._re�'_ - ._.. _• --